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A B M P m e m b e r s ea r n F R E E C E h o u r s by rea d i n g t h i s i s s u e ! 51 I n this companion piece to "Deconstructing Diabetes" (page 36), we will shift our focus from the mechanisms of diabetes as a freestanding disease to the damage it does to a variety of tissues and systems throughout the body. In many ways, this is where the rubber hits the road or where the lubricant contacts the skin: When a client has diabetes, decisions about massage therapy often need to be more informed by its complications than by the fact of diabetes itself. As we go through this substantial (but far from comprehensive) list of things that can go wrong when a person has poorly controlled diabetes, I invite you to take in this information through the filter of your massage therapy practice. What will it mean to you that your client with diabetes is also now at risk for heart attack or stroke? How will it affect your approach to know that your client is planning to start dialysis soon to manage their renal failure? And what about the lucky person who received a new kidney last year—what accommodations might they need? At the conclusion of this column, we'll walk through a simplified critical thinking rubric intended to help readers get a handle on balancing factors related to clients with diabetes and how they guide our understanding of the possible risks, benefits, and appropriate massage therapy accommodations for our clients who live with this very challenging disease. WHAT DOES INSULIN DYSREGULATION DO? As you may have read in the feature article, diabetes causes severe dysregulation of insulin and blood glucose. People with type 2 diabetes often experience a period of hyperinsulinemia as their pancreas tries to accommodate for cells that develop resistance. This state carries its own consequences, some of which can contribute to problems related to diabetes. Later in the process, when the pancreas wears out, hypoinsulinemia can also cause problems. When cells are less responsive to insulin, or when insulin is in short supply, we have only limited access to glucose, our most efficient fuel source. While sugar accumulates in the bloodstream, our cells have a harder time making adenosine triphosphate (ATP). The process becomes much more complex and creates much more in the way of metabolic waste products. KEY POINTS • Most people with diabetes deal with some complications, and this situation must influence decisions about massage therapy. • Consider timing when treating a client with diabetes; it may be best to schedule massage in the middle of an insulin cycle. Meanwhile, having elevated blood glucose stimulates the production of pro-inf lammatory chemicals that also contribute to tissue damage in blood vessels, the kidneys, and more. Some of the complications in this list overlap; for instance, poor circulation related to systemic atherosclerosis can cause secondary problems like skin ulcers or eye damage. And cardiovascular disease raises the risk for both heart attacks and strokes. It is difficult to create firm walls around these categories of problems because, in diabetes, as in all things regarding human health, everything is connected to everything else. But here is an attempt to illuminate some of the most serious complications of diabetes. Insulin molecules