30th wedding anniversary gift

MY GRANDPARENTS' kitchen was the center of their world. In the center of their kitchen was a white enameled table, and on the center of the table sat my grandfather's "works": a blue-bordered white porcelain tray containing a glass syringe with red lettering, a silver needle with a large screw-on hub, a wire for cleaning the needle, and, nearby, the brown sharpening stone for the needle. My grandfather's diabetes was silently accepted by our family; the "D" word was never uttered in his home.

Fifteen years later, while visiting home during my medical internship, my mother took me aside and whispered: "Dad has sugar in his urine. He said that they must have mixed up the samples, but he went back, and they still found sugar." Dad began eating peanuts instead of potato chips, stopped smoking cigars, tilled a larger garden, and lost 40 pounds. Several months later he proudly showed me his lab report: "Blood sugar's only 110--that's just a mild case of glucose intolerance" he told me. "No-sugar" pies became a fixture at family gatherings.

Seventeen years later, I watched a friend run a catheter into my father's heart. A series of tests to diagnose my father's complaint of stomach pains had been negative, and the gastroenterologist suggested a cardiac stress test. Dad reached a high level on the stress test and had no chest pain, but the EKG showed marked changes. As the first shot of dye flashed through my father's heart, the problem seemed obvious: three arteries had clogged so tightly that it was not clear how the dye managed to force its way through. Later, as my friend and I reviewed the results of the catheterization with my father, Dad told us about the sewing machine he got for my mother as a prize for saving 10,000 cigar bands. A quadruple bypass fixed his arteries, and the stomach pains continued their mysterious and episodic visits. But no one ever mentioned the "D" word, and it never showed up on his chart.

Five years later, my wife and I took a 25th wedding anniversary trip, eating our way through Morocco and Spain. I was getting up three or four times at night to go to the bathroom. "Jet lag hits everyone a little differently," I thought, and, after all, we were drinking sticky-sweet Moroccan tea at breakfast, lunch, dinner, and bedtime.

Shortly after we returned from the trip, I noticed at a staff meeting that my left elbow, which had been slightly puffy and itchy for the past week, was growing larger, redder, and more intensely tender by the minute. "Don't pass out," I told myself, as chills and cold sweats swept through me in teeth-chattering waves. After the meeting was over, I walked slowly to the emergency room. "It's a cellulitis and you're going upstairs on IV antibiotics," said my friend, who was the attending emergency room physician.

"Never brought up a doctor before," the orderly proudly told me, as he pushed me on a gurney to the VIP suite in the corner of the fifth floor of the hospital. "You're doing a great job," I told him. Later, dressed in scrubs and with an IV in my right forearm, I looked up my labs on the hospital computer: Glucose 285, Cholesterol 285, HDL 33, and Triglycerides 150. Staphylococcus aureus in blood and elbow pus. "How strange," I thought. My numbers had always been outstanding those few times 20 years ago when I had slipped a sample of my blood off to the lab under a patient's name, just to check it out.

I called my wife to tell her that there was an emergency, and that I had to stay overnight at the hospital. At 2 a.m., waiting for the next IV antibiotic run, I heard scurrying in the room next door, but no one came to my room. I stared at the clock until 2:30 a.m., when I irritably called the front desk to demand my antibiotics. Finally, a harried nurse came into the room with the antibiotic bag. "Sorry I'm late with your med," she puffed, "but we had a cardiac arrest next door." "What do I care about a cardiac arrest, I need my antibiotics," I thought to myself.

Later in the morning, two angels in scrub suits, wearing lineman's belts drooping with nursing paraphernalia, showed up, clipboards in hand, to see how their patient was doing. Suddenly, I understood why patients fall in love with their nurses. The swelling and redness in the arm had decreased, the pain was almost gone, I could bend the elbow, and I was feeling better. I called the home care agency to deliver an IV antibiotic kit to my home and scribbled "discharge patient to home" in my chart. I walked back to my office with the IV still in my right arm, and asked the Cardiology Administrator to drive me home. I never did see my "attending" physician, and some weeks later, when I checked the brief discharge summary, I was relieved to see no mention of the "D" word.

The "D" word. Suddenly, it was everywhere, but thank goodness, not on my chart! I stopped eating doughnuts and bagels, and began eating greens, beans, and leans. I began to jog, at first just around the block, and gradually up to three miles a day. Twenty pounds melted off my middle. I stopped falling asleep during hospital staff meetings, and I no longer had to get up in the middle of meetings and at night to relieve my aching bladder. I had my size 44 suit taken in to a size 42. "The pockets won't look right if I take it in any more," the tailor told me. Patients began telling me how good I looked, but my colleagues began asking me "You're looking pretty thin, is there something wrong with you?"

Was there something wrong with me? Feeling like I was buying condoms for the first time, I went to a drugstore far away from home and hospital and bought a glucose meter. I began checking my blood sugars in the morning, in the evening, and two hours after meals. Strangely, my morning blood sugars were usually around 130, but in the evening, before dinner, the readings were only 79 to 85.

I cautiously broached the subject with one of the hospital endocrinologists. "It's called the dawn effect; before your "patient" wakes up, the cortisol level increases, the liver releases glucose, and the a.m. sugar goes up. If you follow this "patient" long enough, you'll find that in time, the glucose will get higher. That's how it is with diabetes; maybe you should read about it," he said, somewhat patronizingly.

"Maybe that's how it is with diabetes, but it won't happen to me," I thought. And what did I need to know about diabetes? After all, I was a cardiologist, not an endocrinologist.

At the American Heart Association meeting that year, I discovered the American Diabetes Association's modest booth. As I casually flipped through the books and pamphlets, I realized that I had come to the mother lode of diabetes education; I felt like a kid in a candy store, so to speak. "Is there anything I can help you with?" the friendly ADA representative asked me. "No, just looking," I said casually.

As soon as I got home, I sent in my $200 check to the American Diabetes Association and became, I believe, the only cardiologist in Maryland, and one of only a handful in the United States, to belong to the ADA. I learned how to spell "mellitus," and I was thrilled to discover, after a Greek patient gave me a jar of "Meletiadis" as a gift, that Melissa was a Greek goddess, who, because she was a bee, fed the infant Zeus honey (mel).

The jar of Meletiadis ("ingredients: sugar, glucose, vanilla flavor") never made it to my kitchen. I put it on my desk alongside a souvenir coffee mug from our 30th wedding anniversary trip, a hiking tour of the Grand Canyon. The Yin and Yang of diabetes; they are sitting on my desk next to my computer, as I come out of the kitchen, so to speak, and onto this column.

For most of my patients, diabetes is really a cardiovascular disease, occasionally complicated by high blood sugar. I hope to explore the diabetes-heart connection, in all of its amazing diversity, with you. As one of my patients once told me, "Having a heart attack and finding out that I had diabetes was like falling into the privy and coming up with a new suit! Now I know how to take care of myself."

And if we don't take care of ourselves, who will?

Editor's Note: Heart disease is the number one killer of people with diabetes. For this reason, Diabetes Forecast is inaugurating a monthly column on heart health, beginning with this issue.

Sheldon H. Gottlieb, MD, FACC, is a cardiologist at Johns Hopkins Bayview Medical Center, Department of Cardiology, in Baltimore, Md. He also directs the Diabetes-Heart Failure Program at Johns Hopkins HealthCare LLC.