Diabetes 101, or Put Down the Fucking Candy

Edit: This page seems to be getting a lot of traffic, which is unexpected, and I wish now that I'd done a better job of explaining some things about diabetes, both Type I and Type II. I certainly never expected this to be passed around as a PSA!

For those of you just visiting, this blog is a meandering mess of rants and stories about my experiences as a nurse, and the health education aspects are intended to help readers understand a little more about what I handle at work and what it means when I say my pt is "in DKA" or "doesn't take their insulin." I initially made this blog for a pretty small audience of people who were already familiar with my forum posts, and nothing here has been edited or really even thought through. I'd say half of it was written after at least one round of gin & soda.

So what you'll find here may be useful if you're trying to grasp the very basics of hyperglycemia and what it does to the body, but I strongly suggest: if you find this interesting at all, go find some other sources and do more reading. There is SO much more to this topic, and this page-long rant barely begins to scratch the surface.


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A colleague of mine related the tale of a pt, a young man with Type 1 diabetes, who went into diabetic ketoacidosis (DKA) and didn't get appropriate treatment. After a walk-in clinic failed to diagnose his impending health crisis, he went home and chugged sugar syrup-- the drink mix that's poured into soda machines, where it's diluted with carbonated water for serving-- until he lost consciousness. The next day he was delivered by ambulance to the hospital, where he died horribly.

So what the hell, you're thinking. If you know you have diabetes, why would you pound syrup like cheap beer? No, he wasn't just some stupid fuck who wanted a Darwin award. There's a genuine reason for this...

...so it’s pathophysiology time, motherfuckers. (That will be the title of my children’s network show someday.)

We kinda tend to think of insulin and sugar as polar opposites. Too much insulin and your sugar goes away and your brain tissues starve; too little insulin and your blood sugar goes up and, uh, this is bad. Somehow.

That’s really just part of the picture. Yes, the syrupy-thick blood is super bad. Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)

Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.

On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.

But there’s something even more dangerous than just having your blood turn into razor soup. Thick, dense blood is like a sponge, sucking water out of your tissues (read: organs and muscles). When your body enters a diabetic crisis, you become so thirsty you can’t fucking stand it. Undiagnosed diabetics are often spotted because they pack a couple gallon jugs of water to bed with them when they sleep at night. And as soon as their blood thins out a little, their kidneys dump all that new water in an attempt to flush out the sugar, further ripping themselves to shreds… which is why undiagnosed diabetics are also often spotted because they pee themselves in public or spend 2/3 of their day pissing away the gallons of water they’re chugging.

Soda-fountain guy was thirsty as fuck, and all his body’s instincts were telling him to slam a bunch of liquid. But why the fuck choose soda syrup? What the hell?

To answer that one, let’s get back to what insulin does. It doesn’t magically make sugar go away; your cells have their mouths locked shut to keep them from eating every damn thing that goes by, and insulin is the key that unlocks them. If your body doesn’t make insulin (because it destroyed all its own insulin cells), fuckin blows to be you, because your cells will starve surrounded by delicious food. If your body is fat as hell and all that fat is secreting endocrine shit to inform your body that you have enough fucking food to last you a month, your cells become insulin-resistant and it takes a lot more insulin to open those locks. (This part is the least-understood part of the whole fat ---> diabetes cascade, but while we don’t know exactly how it happens, we do know that excess fat leads almost inevitably to insulin resistance, and the ‘almost’ is generous.)

So now your cells can’t eat. Your blood is getting thicker because the onslaught of sugar isn’t slowing, but your cells are starving to death, being ripped apart by sludgy sugar sauce, and having all the water sucked out of them by your spongey thick blood. Insulin also allows your cells to eat the potassium they need to keep their internal pumps running, so now your potassium is backing up, causing your blood to become acidic, and making all your cell’s pumps run backward. In desperation, your cells start burning protein, which is a really poor energy source because it’s actually the cell’s furniture and tools. At this point, shit inside your cells is so bad that instead of putting food on the table, they’re chewing on the table legs in case the varnish is edible.

This is why that poor motherfucker was drinking sugar syrup. He was literally starving to death.

Many diabetics think they have low blood sugar right up until they realize their blood sugar is actually high—their cells just can’t eat any of it.

Broken-down proteins and fats produce ketones. Starving cells produce lactic acid. Between those two and all the extra potassium, your blood turns to acid in your veins. Over time, your kidneys might have been able to slowly compensate for that by secreting bicarbonate, but right now they’re busy squeezing sugar and potassium out through their battered assholes. The only other way your body can try to fix the whole ‘acid blood’ problem is by blowing off as much carbon dioxide as possible, since carbon dioxide is acidic when dissolved in blood. Soon you’re sobbing for air like you’ve been running a marathon (another situation in which stressed-out and starving cells dump tons of lactic acid), your body is so dehydrated you’re losing your mind and your organs are failing, your cells are so hungry they’re literally eating themselves, and so much potassium is backed up in your blood that your heart’s muscle-pumps get overwhelmed by the back-pressure and your heart just… stops.


If you're lucky. Massive organ failure due to combined starvation and shredding is your other, slower option.


DKA is a horrible way to die.


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Addendum: Type 2 diabetics get a similar thing, hyperglycemic hyperosmolar nonketotic syndrome, which does basically the same thing as DKA, but with even higher blood sugars and a lower chance of survival.