Re: half diabetic

November 12, 2000

In a message dated 00-11-12 16:29:06 EST, you write:

<< we could do worse than call them " half diabetics >>

I disagree. As I mentioned earlier, this sounds to me like " borderline

diabetic " , a term that has now been rejected by the medical community - and

even by the Holy ADA. and could be easily mis-interpreted by an

impressionable newbie diabetic. Vicki

November 12, 2000

Thornton wrote:

>

> > ****I believe you're playing with words

> > here, and inaccurate words at that.

> > The accepted medical term is " pre-diabetic " .

> > Was your wife half pregnant, Sam?

>

> That wasn't Sam, Barb, that was me trying to draw some of the heat

> away from poor Sam.

>

> Of course it is playing with words, why not? Words are the only

> thing we have to communicate with here. In the end it all comes down

> to the words we use. I got all worked up when somebody repeated that

> old myth that you either have it or you don't. I can't find the

> expression " pre-diabetic " anywhere in the literature. The latest

> ADA " Clinical Practice Recommendations 2000 " has tightened up the

> stages so that there are only:

>

> - Normoglycemia (normal glucose regulation)

> - Hyperglycemia

>

> But Hyperglycemic is sub-divided into:

>

> - Impaired Glucose Tolerance or Impaired Fasting Glucose

> - Diabetes Mellitus

>

> But none of those are words that describe the person, just the stage

> he/she is at.

>

> I find it easy to call somebody with normoglycemia a " normoglycemic "

> and to call somebody with Diabetes Mellitus a " diabetic " but I am not

> comfortable with calling somebody with Impaired Glucose Tolerance

> a " glucose intolerant " or, worse still, somebody with Impaired

> Fasting Glucose an " impaired glucose faster " . It seems to me that if

> the medics can't come up with a Latin or Greek name for those folks,

> we could do worse than call them " half diabetics " . Do you have a

> better suggestion?

>

> I reject your analogy with " pregnancy " out of hand, Barb. Of course

> there are different stages of pregnancy! You only have to remember

> the old story about the very skinny girl standing up on the bus,

> begging a man to give her his seat as she was pregnant. After she was

> seated he remarked that she certainly didn't look pregnant, in what

> month was she? She answered: No, not months - it was about 30 minutes

> ago. Theoretically she was right but since she hadn't fulfilled all

> the requirements for a secure diagnosis, she was only half pregnant.

>

Dere,

Did you see this article?

http://www.medscape.com/Medscape/CNO/2000/EASD/Story.cfm?story_id=1666

Impaired Glucose Tolerance (IGT) - A Prediabetic

Condition

Z. Zimmet, MD, PhD

A State of the Art Symposium at the 36th Annual Meeting of the

European

Association for the Study of Diabetes in Jerusalem addressed the

important issue

of impaired glucose tolerance (IGT) and the more recently

recommended

classification, impaired fasting glycemia (IFG). Whereas there are

now

considerable data on the epidemiology, natural history, and

consequences of IGT,

it is only recently that data have become available on IFG. A major

issue to

consider is whether IGT and IFG should only be considered risk

factors for type 2

diabetes with IGT being a risk determinant of cardiovascular

disease (CVD) or are

they, like diabetes, diseases in their own right.

Classification of Glucose Tolerance Disorders

Although diabetes mellitus is, in reality, a syndrome characterized

by

hyperglycemia, it has many causes. The 1985 World Health

Organization (WHO)

Study Group classification for disorders of glucose tolerance[1]

included several

clinical classes, the 2 major being insulin-dependent diabetes

mellitus (IDDM;

type 1 diabetes) and non-insulin-dependent diabetes mellitus

(NIDDM; type 2

diabetes), as well as malnutrition-related diabetes, IGT, and

gestational diabetes

mellitus (GDM).

However, a revision in classification was long overdue in light of

new data from

general epidemiologic and etiologic studies. This task was

undertaken by the

American Diabetes Association (ADA) with its 1997 report on

classification[2] and

more recently by the WHO.[3]

Dr. from Phoenix, Arizona, known for his long-time

association with

the Pima Indian studies, discussed the new classification and

diagnostic criteria.

As a result of epidemiologic data, both the ADA[2] and the WHO[3]

recommended

that the new classification be based on stages of glucose tolerance

with

complementary subclassifications according based on the etiology.

As a result, in

the new WHO and ADA classification, hyperglycemia, regardless of

the underlying

cause, is subcategorized and staged as:

Insulin required for survival -- (corresponds to the former

IDDM)

Insulin required for control -- eg, for metabolic control, not

for survival

(corresponds to former insulin-treated NIDDM)

Not insulin requiring -- eg, treatment by nonpharmacologic

methods or by

drugs other than insulin (corresponds to NIDDM on diet

alone/or coupled with

oral agents)

IGT and IFG -- IGT was previously a separate disease class. It

is now

categorized as a stage in the natural history of dysfunctional

carbohydrate

metabolism. IGT is coupled with IFG (6.1-7.0 mmol/L).

From the point of view of revised criteria for abnormal glucose

tolerance:

The fasting plasma glucose (FPG) threshold was lowered from

7.8 to 7.0

mmol/L, based on the risk of microvascular disease.

Impaired fasting glycemia (FPG 6.1-6.9 mmol/L) was introduced

as a new

category for abnormal glucose metabolism (called impaired

fasting glucose

by the ADA), above " normal " but not diagnostic of diabetes.

The ADA (but not the WHO) report recommended that the FPG rather

than the

oral glucose tolerance (OGTT) should be the diagnostic test of

choice both for

clinical and epidemiologic purposes. The ADA recommendation was

mainly made

on the basis of inconvenience of performing the OGTT in clinical

practice.

Are IGT and IFG the Same Condition in Disguise?

Dr. and others including Drs. Rury Holman (United Kingdom),

Heine (The Netherlands), and Jaakko Tuomilehto (Finland), reviewed

data from

several studies such as the National Health and Nutrition

Examination Survey

(NHANES) in the United States, as well as studies conducted in

Europe, Japan,

and Mauritius, which have helped better define differences between

IGT and IFG.

Although there may be some overlap between IGT and IFG, it is now

quite

apparent that they identify different populations. This is,

perhaps, not surprising,

since IFG reflects the basal fasting state and IGT signals

postprandial

abnormalities.

Impaired glucose tolerance appears to occur twice as frequently as

IFG in a

number of epidemiologic studies and is a better predictor of future

development

of diabetes. The Indian Ocean nation of Mauritius provides a unique

population in

which to study the natural history of glucose tolerance. The 1.3

million

inhabitants of Mauritius include people of Asian Indian, Chinese,

and Black

(Creole) descent. Since these ethnic groups constitute nearly two

thirds of the

world population, the data from Mauritius provide a microcosm of

the global

epidemic, making it possible to extrapolate the results to provide

a global

perspective. The data from Mauritius showed that IGT is more

sensitive for

predicting progression to diabetes than is IFG. This occurs at the

cost of only a

small reduction in specificity and positive predictive value.

Thus, whereas the new category of IFG may broaden and improve our

description

of intermediate abnormal states in glucose metabolism, it should be

seen as a

complement to IGT rather than its replacement. Data from other

populations have

confirmed these findings, so screening programs aimed at

identifying people at

risk for diabetes chance missing a considerable amount of

information by relying

solely on fasting glucose values. However, both IFG and IGT are

associated with

a 4- to 5-fold increased risk of diabetes in Pima Indians,[4]

Mauritians[5] and the

population of the Hoorn study from The Netherlands,[6] even though

they are

identifying different individuals. Data from the Pima Indian

studies suggest that

IFG is associated with beta-cell dysfunction whereas IGT appears to

be

associated with hyperinsulinemia. This finding was confirmed in a

recent UK study

by Davies and colleagues[7] which found fasting hyperglycemia to be

associated

with beta-cell dysfunction while IGT was associated with features

of the insulin

resistance syndrome.

Supporting the idea that IFG should be seen as a complement to

rather than a

replacement for IGT, several studies have been published comparing

the old and

new criteria. The overall impression is that the OGTT should be

retained by the

diagnosis of diabetes. Using fasting criteria alone, as recommended

by the ADA,

will cause a significant number of people with diabetes to be

overlooked.

The speakers also addressed the issue of whether type 2 diabetes

can be

prevented in subjects with IGT. A number of international studies

address this

issue, and both the Da Qing study[8] and the Finnish Diabetes

Prevention Study[9]

indicate that weight reduction and exercise are effective in this

respect. Professor

Rury Holman from the United Kingdom Prospective Diabetes Study

group showed

data that suggest that a deterioration of beta-cell function

commences at least

10 years before the clinical onset of diabetes. Therefore, the

earlier the

intervention, the better. Several studies are either under way or

are being

planned to examine whether therapeutic intervention with drugs such

as

alpha-glucosidase inhibitors, angiotensin-converting enzyme (ACE)

inhibitors, and

thiazolidinediones might be used for prevention as well.

Is IFG Associated With Increased Risk of Cardiovascular Disease?

The ADA hoped that their recommendations to use fasting glucose

alone would

simplify diagnosis of diabetes. Alas, that has not been the outcome

and their

recommendations are further clouded by the fact that IGT is a far

better predictor

of risk from both all-cause and CVD mortality. Dr. cited

several studies

including those from Mauritius, Samoa, and Nauru, as well as the

Funagata Study

from Japan and the European Decode study, which indicate that

whereas IGT is

associated with increased CVD risk, this is not the case for IFG.

Dr. Tuomilehto addressed the issue of IGT as an independent risk

factor for CVD.

He reaffirmed that data from a number of studies indicate that IGT

carries a

significant risk of CVD whereas IFG does not. He concluded that the

relationship

between 2-hour glucose level and CVD risk is analogous to that of

to serum

cholesterol and CVD risk; there is no threshold for CVD risk, and

the lower the

blood glucose the better.

Conclusions

In summarizing, Professor Sir Alberti, President-Elect of

the International

Diabetes Federation (IDF), and President of the Royal College of

Physicians,

London, England, pointed out:

Whereas the new category of IFG may broaden and improve our

description

of states of abnormal glucose metabolism, it should be seen as

complementing rather than replacing IGT.

IGT but not IFG is associated with increased risk of CVD and

is, in most

studies, a stronger predictor of future diabetes.

IFG may result from beta-cell dysfunction while IGT is

associated with

hyperinsulinema/insulin resistance, suggesting different

etiologies for these

states of impaired glucose metabolism.

What is not yet known is whether treatment of IGT and IFG

specifically can

delay or prevent the appearance of macrovascular disease.

However,

delaying the onset of diabetes in such high-risk subjects will

itself provide

benefit in terms of morbidity and mortality. It may therefore

be prudent to

treat such individuals with, at the least, lifestyle advice or

with

glucose-lowering agents of proven long-term safety while more

data are

accumulated.

References

1.World Health Organization: Diabetes Mellitus: Report of a WHO

Study Group.

Geneva: World Health Organization; 1985 (Tech Rep Ser, no.

727).

2.The Expert Committee on the Diagnosis and Classification of

Diabetes

Mellitus. Report of the expert committee on the diagnosis and

classification

of diabetes mellitus. Diabetes Care. 1997;20:1183-1197.

3.World Health Organization: Definition, diagnosis and

classification of

diabetes mellitus and its complications: Report of a WHO

Consultation. Part

1. Diagnosis and classification of diabetes mellitus. Geneva:

World Health

Organization; 1999.

4.Gabir MM, Hanson RL, Dabelea D, et al. The 1997 American

Diabetes

Association and 1999 World Health Organization criteria for

hyperglycemia in

the diagnosis and prediction of diabetes. Diabetes Care.

2000;23:1108-1112.

5.Boyko EJ, de Courten M, Zimmet PZ, et al. Features of the

metabolic

syndrome predict higher risk of diabetes and impaired glucose

tolerance: a

prospective study in Mauritius. Diabetes Care.

2000;23:1242-1248.

6.de Vegt F, Dekker JM, Stehouwer CD, et al. The 1997 American

Diabetes

Association criteria versus the 1985 World Health Organization

criteria for

the diagnosis of abnormal glucose tolerance: poor agreement in

the Hoorn

Study. Diabetes Care. 1998;21:1686-1690.

7.Davies MJ, NT, Day JL, et al. Impaired glucose

tolerance and

fasting hyperglycaemia have different characteristics. Diabet

Med.

2000;17:433-440.

8.Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in

preventing

NIDDM in people with impaired glucose tolerance. The Da Qing

IGT and

Diabetes Study. Diabetes Care. 1997;20:537-544.

9.Uusitupa M, Louheranta A, Lindstrom J, et al. The Finnish

Diabetes

Prevention Study. Br J Nutr. 2000;83(Suppl 1):S137-142.

>

--

Dave -- Sunday, November 12, 2000

t2 8/98 Glucophage

ICQ 10312009

«»

DavOr's daily aphorism:

* I get enough exercise just pushing my luck.

--

Visit my photo page @ http://www.dorcutt.homepage.com

November 12, 2000

In a message dated 00-11-12 21:47:48 EST, you write:

<<

Vicki, as I recall you are type 1, IDDM. It must be much more dramatic

for you , but there is a range of diabetic all the way from IGT to type

1. Theres no falling off a cliff, It's like the variance in any group. I

can't see why you insist on hard boundaries, there aren't any. Sam

>>

I don't recall saying anything about " hard boundaries " . I realize -- and we

all should -- that diabetes exists on a continuum. I think I even mentioned

this in an earlier post .

yesterday or today. Vicki

November 12, 2000

In a message dated 00-11-12 21:47:48 EST, you write:

<<

Vicki, as I recall you are type 1, IDDM. It must be much more dramatic

for you , but there is a range of diabetic all the way from IGT to type

1. Theres no falling off a cliff, It's like the variance in any group. I

can't see why you insist on hard boundaries, there aren't any. Sam

>>

Ah, just read post from Bob . He's the one who referred to " hard

boundaries " You must've gotten us mixed up, Sam. Don't kow why...we don't

look at all alike.

:-) Vicki

November 12, 2000

Vicki, as I recall you are type 1, IDDM. It must be much more dramatic

for you , but there is a range of diabetic all the way from IGT to type

1. Theres no falling off a cliff, It's like the variance in any group. I

can't see why you insist on hard boundaries, there aren't any. Sam

November 12, 2000

> << we could do worse than call them " half diabetics >>

>

> I disagree. As I mentioned earlier, this sounds to me like " borderline

> diabetic " , a term that has now been rejected by the medical community - and

> even by the Holy ADA. and could be easily mis-interpreted by an

> impressionable newbie diabetic. Vicki

Some semantic tension surrounds these terms 'half-diabetic', and

'borderline diabetic'. Personally, I think we diabetics hold fast to an

absolute notion of our disease. Words like 'half' or 'border' have

connotations which somehow threaten the chiseled, sharp, outlines we cut

to represent our own disease.

It's a solidarity measure as well, the eschewing of 'half' and 'border',

for it allows no mistake to be made about who is, or isn't within our

community. It's as much about identity, I submit, as about the nature of

the disease. Fuzzy borders around identity undermine the self-drawn

pictures of who we think we are.

But tension surfaces again, only this time *within* our community. This

tension exists between our drawing sharp, incisive, deep-cut lines between

who is or isn't diabetic, and our expansive tolerance towards plains of

possible *differences* *within* on our own community, on this side of the

cut-lines. Within our community we allow for, even encourage each other to

compare our incredibly wide ranging responses and symptoms of diabetes.

Within our community we accept borderlines between each other, almost

without thought, certainly without question in many instances. We allow

that every diabetic occupies a unique point along a continuum where no one

diabetic is exactly like any other.

This sharp contrast in perspective from that towards 'outsiders' or

'border-crosser', and our own residents, lead me to think that terms like

'borderline' or 'half-diabetic' have more to do with attitudes than

biology. Or at least as much.

Bob

******************************

November 13, 2000

> Did you see this article?

> http://www.medscape.com/Medscape/CNO/2000/EASD/

> Story.cfm?story_id=1666

> Impaired Glucose Tolerance (IGT) - A Prediabetic

> Condition

No, I hadn't seen that yet, Dave, so thanks.

I can't help feeling that maybe we ought to wait until all the

professors and doctors have stopped quarrelling with each other

before we even read any of this stuff!

It's almost like lying in bed in hospital and hearing the medical

staff arguing about what would be the best treatment and why not.

Something like that happened to me when I was alleged to have

diverticulitis and they started arguing about what to do next. I can

remember asking them if this was a diagnosis or an autopsy and they

just went out into the corridor to continue arguing out there.

As a recently enrolled lifetime member of the diabetes club, I want

to believe that there is some solid science behind all this and not

that these guys change the basic rules from one conference to the

next. What made them choose Jerusalem of all places? That's not

exactly an environment conducive to reaching a unanimous agreement!

I get the impression that there are plenty of ideas about what

correlates to what but very little work is being done on the why?s

and how?s. I hope I am wrong!

November 13, 2000

> This sharp contrast in perspective

> from that towards 'outsiders' or

> 'border-crosser', and our own residents,

> lead me to think that terms like

> 'borderline' or 'half-diabetic' have more

> to do with attitudes than biology. Or at

> least as much.

Yes, I think so too, Bob. The biology is very complicated and we

strive to simplify our view of it in an attempt to make it

understandable. The 'attitude' aspect, in my opinion, relates to the

impression of having passed the 'point-of-no-return' - the

implication being that a 'half-diabetic' stands a chance of turning

it around and getting back to the other side again whereas a full

diabetic has cut the rope already.

I can well imagine that somebody who pines for normoglycemia would

resent the idea that some people still believe in a cure or at least

in neutralization of the disease. It doesn't bother me, and I am

willing to accept the idea that some people have a mild touch of it

and can return to near normal with a little effort.

Probably, the rage that mounts when the term " half diabetic " appears

says more about the person who gets excited about it than it does

about the person who uses the term.

Ah, well! A little excitement now and again helps to pass the time

away.

November 13, 2000

Based on some arbitrary guideline set by the medical community, doctors proclaim

their patients to be diabetic, pre-diabetic or borderline diabetic. And if they

are being formal, they may even assign their patients to acronym, IGT, IFG, DM,

whatever. Then the World Health Organization comes along and says, oooops, we

changed our minds, this reading is not a normal one anymore... this new one is

real. All of a sudden, people who were formerly pre-diabetic, or borderline are

suddenly reclassified. At the whim of some organization's definition.

Yes, this disease is classified on a continuum, but the fact remains, we must

all

watch these numbers carefully, and try to keep them in the normal range as much

as possible. By assigning people classifications such as " pre " and " borderline "

can give them a sense of false security, that somehow they are not diabetic. And

people will cling on to this hope, like a terrier, and will not let go. When in

fact, they have to watch their glucose response just as diligently, to make sure

that they don't tip into this arbitrary definition.

Even diabetics who thought they had good control, under the guidelines

previously

set by the WHO, found themselves that ooops, it wasn't such good control after

all... they changed their minds again.

November 13, 2000

> Even diabetics who thought they had

> good control, under the guidelines

> previously set by the WHO, found themselves

> that ooops, it wasn't such good control

> after all... they changed their minds again.

, are you sure that the WHO uses the attribute " good " ? My

impression is that only diabetics themselves use " good " and " poor "

(but InCharge also, as a marketing gag). I prefer to use the

term " close control " which to me means nothing much more than that

the diabetic is monitoring BG him/herself instead of just waiting for

the quarterly HbA1c results and does not say anything about the

improvement that has been achieved.

In Germany, they tend to distinguish between 'standard' treatment

and 'intensive' treatment, the difference being that with intensive

treatment an attempt is made (by means of home BG monitoring) to

steer the dosage a little closer to the hypo range than is the case

with the standard treatment in which home BG measurements are not

made at all and the treatment goal is therefore set correspondingly

higher (higher HbA1c, that is).

To me " good control " also says nothing about the numerical value

measured but refers only to the amount of effort put into the

monitoring and the effectiveness of the response to the information

obtained from it. " Poor control " meaning that the diabetic is not

really bothering, that's what the doctor is being paid for.

November 13, 2000

> By assigning people classifications

> such as " pre " and " borderline " can

> give them a sense of false security,

> that somehow they are not diabetic.

But by definition they really aren't diabetic, , that is the

whole point of the discussion. The differentiation made by the new

classification is that we are all divided into normoglycemic and

hyperglycemic.

And the hyperglycemics are divided into:

- the hyperglycemics who have diabetes mellitus (i.e. the diabetics)

and

- the hyperglycemics who have IGT and/or IFG.

There is no point whatever having a division if you then suggest that

all are diabetics anyway. Anybody with hyperglycemia who does not

meet the definition of diabetes mellitus is therefore undeniably NOT

a diabetic - but he/she is also not normoglycemic so what do we call

them?

One solution is to call them " pre-diabetics " or " borderline

diabetics " or " half diabetics " but that obviously muddies the water.

Another way out is to call them IGTs of IFTs or even " IGT and/or

IFT " s but what a mess!

I appeal to the entire medical profession to think up a Greek or

Latin name that will fit that bunch!

November 13, 2000

http://www.inchargenow.com/Complete_Control/relationship.htm

The above link compares the Glucoprotein number to a HBA1C

The BG numbers they use are the US numbers

>

>To me " good control " also says nothing about the numerical value

>measured but refers only to the amount of effort put into the

>monitoring and the effectiveness of the response to the information

>obtained from it. " Poor control " meaning that the diabetic is not

>really bothering, that's what the doctor is being paid for.

>

>Public website for Diabetes International:

>http://www.msteri.com/diabetes-info/diabetes_int

>

November 13, 2000

In a message dated 11/13/2000 9:37:31 AM Eastern Standard Time,

n8rwatch@... writes:

> Half, whole, or bordered with pink polka dots, a person with diabetes or

> insulin resistance or hypoglycemia has a problem with sugar

> metabolism. Accept it and deal with it.

>

Yes, many diabetics as with any chronic disease do have to deal with denial

at some point :-)

carol

November 13, 2000

In a message dated 11/13/2000 12:35:35 PM Eastern Standard Time,

lists@... writes:

> It hurts like hell and they didn't give me anything at all for the

> pain, which lasted from 4:00 am on a Sunday (woke me up) until 10:30

> am on the following Wednesday.

>

Sorry to hear this, but to put it simply it is tiny little nodules on the

inside of the intestine, to help control the pain don't eat anything with

seeds, as it could get stuck, even popcorn, anything made from in any way,

seeds.

carol

November 13, 2000

Since this started with Sam's comment to me, I'll add in here that part of my

strong response is that with my family history and some other medical problems I

have, diabetes scares the daylights out of me. I have glaucoma. If I don't

control my glucose levels, I could very well lose my vision. Even more

terrifying is that my grandmother died at the age of 64, father at age of 59,

and uncle at the age of 59 -- all of them from NOT taking care of their

diabetes. So, did the comment elicit a strong response? You bet it did.

Re: half diabetic

> This sharp contrast in perspective

> from that towards 'outsiders' or

> 'border-crosser', and our own residents,

> lead me to think that terms like

> 'borderline' or 'half-diabetic' have more

> to do with attitudes than biology. Or at

> least as much.

Yes, I think so too, Bob. The biology is very complicated and we

strive to simplify our view of it in an attempt to make it

understandable. The 'attitude' aspect, in my opinion, relates to the

impression of having passed the 'point-of-no-return' - the

implication being that a 'half-diabetic' stands a chance of turning

it around and getting back to the other side again whereas a full

diabetic has cut the rope already.

I can well imagine that somebody who pines for normoglycemia would

resent the idea that some people still believe in a cure or at least

in neutralization of the disease. It doesn't bother me, and I am

willing to accept the idea that some people have a mild touch of it

and can return to near normal with a little effort.

Probably, the rage that mounts when the term " half diabetic " appears

says more about the person who gets excited about it than it does

about the person who uses the term.

Ah, well! A little excitement now and again helps to pass the time

away.

eGroups Sponsor

Public website for Diabetes International:

http://www.msteri.com/diabetes-info/diabetes_int

November 13, 2000

Thanks so much for that report, Dave. That was most interesting!

" The ADA (but not the WHO) report recommended that the FPG rather than the

oral glucose tolerance (OGTT) should be the diagnostic test of choice both

for clinical and epidemiologic purposes. The ADA recommendation was mainly

made on the basis of inconvenience of performing the OGTT in clinical

practice. "

There's the ADA, once again recommending an a diagnostic test that is a less

reliable indicator of diabetes and heart disease, even though WHO opposed

it, because it is more convenient for the doctors.

*sound of teeth gnashing *

Susie

November 13, 2000

I find this whole thing ridiculous folks, and I would suggest that we ignore

such word playing. I

think Barb we should ignore things of this sort.........And I think that we

would all agree what

ever you call " half diabetic " " pre diabetic " " bordeline diabetic " " glucose

intolerant " etc, that

whatever term you use, there is something obviously medically wrong and thus the

person should be

watched closely and tested frequently by their doctor and/or be receiving

treatment. I mean to just

ignore a condition or a developing condition just because it does not meet

someone's criteria is

ridiculous. People don't take this disease seriously anymore.