I woke up startled in the middle of the night, sweating and trembling. Stumbling out of bed, weak and tired, I grasped the air searching for a small black kit. As I unzipped it, I knew the feeling right away: hypoglycemia, or low blood sugar. A small drop of blood and a quick test confirmed it. A double take — my blood sugar was lower than it had ever been.
I was diagnosed with Type 1 diabetes in November 2008, and waking up in the middle of the night with low blood sugar is something for which I’m typically prepared. But my blood glucose level was able to get so low on that October night during my freshman year of college because my body did not alert me, which it usually does.
Even prior to coming to college, I had known that alcohol consumption is quite dangerous for a diabetic, because it has the capacity to rapidly lower blood sugar. It also reduces the body’s senses, meaning that you'd be less likely to wake up from hypoglycemic symptoms. Yet earlier that evening, I had done the typical freshman college Saturday night out, though with far less alcohol than the average partier. That night, I had consumed less than two alcoholic drinks.
Any number below 70 milligrams per deciliter is considered low blood sugar. That night, my number dropped to 27.
Welcome to college.
Life with diabetes
Northwestern freshman and diabetic Aileen McGraw wakes up almost every morning at 7 a.m., even if she doesn’t have class. She sticks to a regimented schedule, timing out meals and snacks to ensure that her blood sugar levels do not drop too low or rise too high. McGraw uses an insulin pump, which stays attached to her body and delivers insulin periodically throughout the day and mostly during meals. She also sticks to a regimented diet designed to prevent undesirable blood sugar numbers. Her entire lifestyle revolves around managing her diabetes.
Diabetes mellitus is a disease that affects 8.3 percent of Americans, according to a report released in early 2011 by the Centers for Disease Control and Prevention (CDC). And that number is on the rise throughout the world. Type 1 diabetes -- also known as juvenile diabetes -- basically occurs when the pancreas ceases to function properly. Essentially the pancreas stops producing insulin, which leads to increased glucose in both the blood and urine. This form of diabetes, which is entirely hereditary, is treated by infusing insulin into the body, either through injection or some device like an insulin pump.
Diabetics have to take certain amounts of insulin in accordance with food intake and blood glucose level in order to keep their blood sugar at a desirable level. Failure to monitor these levels can result in severe short-term and long-term consequences; the goal is to keep blood sugar within the range of 80 to 120, although these numbers vary. Eating carbohydrates raises one’s blood glucose level; insulin lowers it. Blood sugar, by the way, is defined as the amount of glucose in the blood stream and urine.
Unfortunately for diabetics like myself, college isn't exactly the best place to control such a disease. One of the most important aspects of regulating diabetes is to avoid excess and maintain discipline. College life discourages both. Whether it’s the easy availability of large quantities of food, the accessibility of alcohol or even what Northwestern sophomore and diabetic Jackson Herzog calls the “spontaneity of college,” controlling the disease is extremely difficult in this environment. The attention to detail and the 24/7 effort required to effectively control diabetes is antithetical to the busy and erratic nature of college life.
"The best way obviously to control your blood sugar is to really have a pretty strict schedule of eating, which kind of implies a pretty strict schedule of other things,” Herzog says. “[But in college] there’s just so many things happening that sometimes you don’t get a chance to really structure your own schedule.
Let it slip from your mind for a minute, and your blood sugar shoots up above 200 – or even higher. Maybe it drops too low, below 70. The inability to escape a string of high blood sugar readings – hyperglycemia – or a pattern of lows, leads to aggravation and stress. Mostly because of the long-term consequences that lie in wait.
But part of the problem of dealing with poor blood sugar levels is that the effects aren't always immediately apparent. Hypoglycemia -- low blood sugar -- is indeed very noticeable to the body. Symptoms of hypoglycemia include weakness, sweat, hunger, trembling, blurry vision as well as a number of other indicators. If glucose drops too low, passing out or even death is not out of the question. However, hyperglycemia -- high blood sugar -- is not as obvious in the short-term. If one’s blood sugar gets high enough, signs of hyperglycemia can include extreme thirst, blurred vision, fatigue and a host of other symptoms. The issue is that if one’s blood sugar is high but not extremely high -- say around 200 -- the body feels relatively normal. For many people, this means no incentive to monitor blood glucose and keep it within the desired range -- an essential range to maintain long-term health.
Although I'm not looking for sympathy and I'm the first to admit that there are other far worse diseases out there, managing diabetes is not easy. It requires focus and resolve, and leaves little margin for error. Even if I’m absolutely certain I have done everything right – eaten the right amount of food, given the proper insulin, etc. -- something could easily go wrong.
One mistake can result in an undesirable blood glucose level. That results in extreme frustration and angst. Add up all those single mistakes over time and my body will face destruction.
Herzog experiences similar feelings of frustration, such as when his blood sugar drops low at night and he can’t sleep, or when it’s too low to exercise and he has to delay a trip to the gym.
“Sometimes when I’m being a little reactionary with my pump, after I eat a bunch I’ll take an amount of insulin and get low, then I’ll eat something and get high, and then I can’t get it under control,” Herzog says. “I’m just like, ‘What do you want from me?’”
Planning life around food
Everything for diabetics revolves largely around eating. But the concept that diabetics cannot eat any sugar is a myth. Increasing sugar intake raises blood sugar increasingly fast, but that does not mean sugar is completely off-limits. Except in cases of hypoglycemia, when blood sugar needs to be raised quickly -- it should be consumed on a limited scale.
College students stereotypically eat unhealthy food, a stereotype that has at least proven true among my friends. Ordering wings or pizza (or both!) late at night, or making a run for a burger and fries in the evening is ingrained in Northwestern culture. While indulging in these types of food isn't completely taboo for a diabetic, it requires tremendous self-will to say no. Even though it’s necessary to avoid these types of foods to maintain health in the long run, the wide consumption of such foods in college makes it tempting to simply take insulin and hope for the best.
While eating sugary or unhealthy foods can be tempting, especially with the unhealthy nature of many college students, a disciplined diabetic can limit their intake of sugary foods. Where it can become difficult is limiting the sheer quantity of carbohydrates consumed, as high carbohydrate diets are more difficult to control than low-carb (though definitely not no-carb) diets. “It’s not necessarily the actual sugar you’re being deprived of, it’s the amount of food and it took some while to get used to,” Herzog says.
Herzog says that adjusting to dining hall meals was one of his biggest challenges initially when he arrived at Northwestern. Because he says he can eat a lot of food in a short amount of time -- and because Northwestern’s dining halls essentially allow for unlimited consumption -- the dining hall proved to be problematic to his health. This year, he lives in his fraternity house, meaning that he does not eat in the dining halls nearly as regularly. It has vastly improved his mealtime management.
Eating is strategic. I have to consider timing, carbohydrates, sugar, blood glucose level, preceding meals, upcoming meals, potential exercise and a host of other factors before I eat so little as a snack, not to mention a meal. Without attention to detail, maintaining this discipline is very difficult in a college atmosphere due to its spontaneity. If my girlfriend or a fraternity brother asks me to eat lunch, for example, I’m usually going to accept that request. This can become problematic because of the unpredictable nature of diabetes. At times, my blood glucose level is not always ideal when I’m ready to eat. Normally, I will try to wait for it to either raise or lower before I eat a meal. If I'm meeting someone to eat, though -- something that occurs with some frequency and often unpredictably in a college setting -- it becomes easier to justify cutting a few corners in the name of normality. Cutting corners, though, can lead to more undesirable blood glucose levels, and thus consequences down the road.
Being so busy also doesn't help, even on a regimented schedule.
“I feel like every Northwestern student has every minute of their day planned,” McGraw says. “There just might be more flexibility (for non-diabetics).”
“It always has to be on my mind”
Staying healthy and safe requires a diabetic to know what lies ahead and plan for it. For example, before I leave my room for the day, I make sure I have enough insulin in my insulin pump, blood test trips, alcohol swabs, snacks, sugary food in case of hypoglycemia and a number of other supplies. These are things that the average college student does not have to think about. And diabetics have to think about them all the time.
This is where life in college can get complicated for a diabetic. College is defined by spontaneity and irregularity: Long days of class, extremely late hours, rough mornings, unplanned adventures and other spur-of-the-moment activities might be commonplace for most students, but they can be challenging for diabetics. Because diabetics without complications are not very noticeably different from the average college student, the desire for normality leads to temptation and a lack of discipline.
“Some of it is obviously on me, because I have to realize that this is a chronic illness at this point and it always has to be on my mind,” Herzog says. “But to a certain degree, it’s the environment you’re in that makes it a lot tougher.”
Although Herzog has a better handle on managing the disease today, the adjustment period was difficult during his freshman year. Finally independent from parents, it is tough to maintain that vigilance required to regulate blood glucose levels. Although Herzog’s parents played a smaller role helping him regulate his diabetes as he grew older, they were still always a presence to remind him of his health obligations. I shared the same experience: Without my parents around at school, though I have never disregarded my health, I haven’t had the constant voice in my head reminding me to prioritize it. It makes a big difference, because part of controlling diabetes is thinking about it at almost all times.
McGraw, who has been diabetic since she was five years old, says that the biggest adjustment for her arriving at college was managing her diabetes independently. She previously relied on her mom to handle all pharmacy dealings, such as picking up insulin, test strips, insulin pump supplies and various other items. When she arrived at Northwestern, suddenly she was managing her supplies on her own, which proved to be a major adjustment.
In the past school year, for example, McGraw has lost track of her pump materials, and realized too late that she was in need of something. Without these materials, the pump cannot function and deliver insulin. Luckily, because she lives in the Chicago area, her mom was able to bring supplies to her from home.
Keeping track of the supplies necessary to manage the disease can be difficult on its own. Actually managing the disease can be impossible sometimes, as on some occasions it is simply impossible to control due to external factors.
Just like insulin is not the only way to lower blood sugar -- exercise, for instance, can have a lowering effect on glucose levels -- food is not the only thing that raises blood glucose. In fact, stress can affect blood sugar levels, usually causing them to rise.
“When you’re stressed, your body releases a number of hormones,” says Dr. Mark Molitch, a professor of Medicine-Endocrinology at Northwestern’s Feinberg School of Medicine. “All of them work to raise blood sugar levels. So they sort of work against insulin to raise blood sugar levels.”
Stress is a major facet of college life. Between exams, other studies, extracurricular activities, job prospects and elsewhere, college students are more stressed now than ever. For diabetics, the consequences of constant stress can be high blood glucose levels, which can have serious long-term consequences.
The danger of alcohol
While most of the prevalent effects of diabetes are long-term in nature, the disease can also have devastating effects in the short-term if not managed correctly. The likeliest route to early scares or even death is through extremely low blood sugar, which can occur as a result of alcohol consumption. In an article for the American Diabetes Association, Dr. David C. Mellinger notes the potential direct and indirect dangers of drinking alcohol for diabetics. “Alcohol-induced hypoglycemia occurs mainly in patients in the fasted state and is related to alcohol’s ability to block gluconeogenesis, thus limiting one of the body’s responses to a low blood glucose level,” he writes. “Indirectly, alcohol can impair judgment and cause people to forget to monitor their blood glucose or even eat."
Mellinger also acknowledges that alcohol can impair the “hyperglycemic awareness” of diabetics, meaning that the body has a lessened awareness of low blood glucose symptoms. This is what I experienced on that October night during my freshman year. Although I woke up and was able to correct my blood sugar, not everyone is so lucky. “Alcohol has the unfortunate tendency of counteracting the body’s normal mechanism for countering hypoglycemia,” Dr. Molitch explains.
These concerns are not to say that alcohol is not off-limits for diabetics. McGraw says she is in good control of her diabetes, yet doesn’t have many issues with partying, even though she has had several scares with very low blood sugar (though not all were related to alcohol). Herzog, though, says he has vastly decreased his alcohol intake this quarter, which has greatly improved his blood glucose numbers.
“It’s something that took me awhile to realize. You can still have fun, but it’s just not for me because it’s going to really impair my health in the future,” Herzog says. “It took me awhile to realize I couldn’t handle it as much as I thought I could.”
Unlike the consequences of normal mismanagement, which do bodily harm gradually over a long period of time, improper consumption of alcohol has the ability to kill a diabetic in one night.
Doctors and experts recommend consuming alcohol in moderation; the problem is that moderate consumption is not typically aligned with the classic perception of a college drinking experience. Although all of my friends completely understand why I barely if ever consume alcohol, this inability to fully partake in alcohol activities can lead to some sense of exclusion. At a party, while others are occupied playing drinking games, for example, I feel awkward standing around or just drifting from group to group, unable to participate in the main attraction.
Awkwardness won’t kill me. Alcohol would.
Searching for normality
This sense of being different is one of the great juxtapositions of diabetes. Everything about the person may seem normal at first glance – there’s no obvious signs of a disability, outside of a barely noticeable insulin pump and a few supplies. Yet in order to maintain healthy control over the disease, a diabetic must realize that he or she is not the same as other college students. Diabetes should not and does not prevent me from doing the things I want to do; however, while I do certain activities or even go about my daily life I constantly remind myself of my chronic condition, and how my future depends on it.
Serious problems with vision, kidneys, nerves, feet and other places of the body can occur if blood sugars are chronically high. One tactic I use to maintain discipline and avoid hyperglycemia is to envision an older version of myself, hobbled and destroyed by various complications of the disease. This older me is almost blind, with kidney disease and amputated feet. I’m at serious risk for heart attack and gum disease.
That’s the guy I don’t want to become, and I work hard to avoid glucose levels that will lead me down this path. Yet because long-term complications are not apparent at first, there are diabetics that are on their way to that type of life.
For many, college is a time to have fun without thinking about the future, at least for a couple years. No regrets, you only live once, live life one day at a time. Every day I have to remind myself why this philosophy would have disastrous consequences for me as a diabetic. Even though I must focus on my condition one day -- perhaps even an hour or minute -- at a time, forgetting about the future would lead me to lose that future. I don’t want a carefree college attitude to get in the way of my grandchildren interacting with a healthy grandfather one day, or even prohibiting them from meeting their grandfather at all.
I admit that I can be hard on myself when I find myself experiencing a string of high blood glucose readings or multiple low blood sugars. I remind myself of the horrible consequences that could ensue, which is perhaps a terrible way of looking at life but nonetheless it forces me to be more accountable.
“How you control it is going to be a huge factor in determining how long you live,” Herzog says. “You do have to always remember the long-term consequences because it is a chronic illness.”
My first reaction when I was diagnosed with diabetes -- after weeks of extreme thirst, painful cramps, frequent cramps and fatigue -- was to be thankful that I did not have some worse disease. Diabetes can be fatal, but it can also be managed. Yet in trying to be a normal college student, I sometimes lose sight of the fact that my body isn’t normal. And if I don’t realize that soon, the façade of normality associated with diabetes will fade as I age and long-term consequences set in.
College only happens once, yes. But so does life.
By Stanley Kay