Diabetes & Breath Alcohol Testing - Part 1
Counterpoint Journal, Volume 2; Issue 1 - Article 5 (June 2017)
Jan Semenoff, BA, EMA
Forensic Criminalist
Here is a quick take-away from this article:
- Diabetes (Diabetes Mellitus) is a chronic metabolic disease that reduces or eliminates the body’s natural production of Insulin in the pancreas.
- Diabetes is broadly classified into three main types: Type 1, Type 2, and Gestational Diabetes.
- The classic early warning symptoms of diabetes include frequent urination and increased hunger and thirst levels.
- Your client may have undiagnosed diabetes, and not even know that they have the signs and symptoms of the disease. Potentially, this could affect their breath test results.
- In Type 1 Diabetes, these symptoms may develop rapidly over a few months or even a few weeks.
- In Type 2 Diabetes, the development of symptoms may be subtle, taking longer to develop, or absent altogether.
- Diabetic emergencies are divided into two types: Hyperglycemia (Diabetic Ketoacidosis) and Hypoglycemia (Insulin Shock).
- Practice tips are included throughout the article.
Why is diabetes a concern in breath alcohol testing?
Breath test results are predicated on the assumption that the test subject is an average person, with average physiological responses, providing an average breath sample. That breath sample is then reported as a blood alcohol concentration using average values in the basic assumption used for conversion. Underlying or pre-existing medical conditions can upset those assumptions. This article will address the medical condition of Diabetes. The follow up article in Part 2 will discuss how the diabetic condition may impact the reliability of reported breath alcohol concentrations, and affect your client's reported indicia of impairment, and their performance on the Field Sobriety tests..
Almost 10% of the population (30 million Americans, and 3.4 million Canadians) have diabetes. It is important to know that your client may have diabetes, or early onset prediabetes and not even know it. An additional 20 million Americans and 6 million Canadians have undiagnosed prediabetes.
I have consulted on cases when the initial report from the lawyer indicated NO diabetic history or condition reported by the client. After listening to the facts of the case, I've recommended testing of the client by their health care provider. About a dozen or so times, previously undiscovered diabetes was diagnosed in the client.
Almost 10% of the population (30 million Americans, and 3.4 million Canadians) have diabetes. It is important to know that your client may have diabetes, or early onset prediabetes and not even know it. An additional 20 million Americans and 6 million Canadians have undiagnosed prediabetes.
I have consulted on cases when the initial report from the lawyer indicated NO diabetic history or condition reported by the client. After listening to the facts of the case, I've recommended testing of the client by their health care provider. About a dozen or so times, previously undiscovered diabetes was diagnosed in the client.
What is Diabetes? (Diabetes Mellitus)
Figure 1 - The pancreas is a glandular organ that is in both the digestive and endocrine systems in vertebrates. It produces hormones, including insulin and glucagon, plus pancreatic juices that contain digestive enzymes.
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Diabetes (Diabetes Mellitus) is a chronic metabolic disease that reduces or eliminates the body’s natural production of Insulin in the pancreas. In general, this produces high blood sugar (glucose) levels, either through lower production of insulin, or because body cells do not respond effectively to the insulin that is produced. It is the high blood sugar that creates three classic symptoms of diabetes:
[1] Insulin was developed in 1921 by Canadian physicians Sir Frederick Banting of Ontario and Dr. Charles Best, originally from Maine. |
Types of diabetes:
Diabetes is broadly classified into three main types: Type 1, Type 2, and Gestational Diabetes:
- Type 1 Diabetes results from the body’s inability to produce adequate insulin levels, resulting in an absolute insulin deficiency. Persons with Type 1 diabetes require insulin injections to control their blood sugar levels. It accounts for about 10% of all diabetes cases. It was traditionally referred to as juvenile diabetes, due to its onset in children.
- Type 2 Diabetes is a product of insulin resistance. Body cells cannot use the naturally occurring insulin properly, resulting in insulin deficiency. This was formerly referred to as non-insulin dependent diabetes, or adult-onset diabetes. It is the most common type of diabetes.
- Gestational Diabetes develops when pregnant women who have never had diabetes before have high blood-glucose levels during pregnancy. It occurs in 2-5% of all pregnancies. This may disappear following pregnancy, or be the precursor for Type 2 Diabetes after the pregnancy.
Prediabetes - the potential hidden factor in your case:
IMPORTANT: Prediabetes is a condition that occurs when the person’s blood glucose levels are higher than normal, but not high enough for a diagnosis of Type 2 Diabetes. Nearly half of all people with prediabetes will go on the develop Type 2 Diabetes.
It is estimated that almost 30 million Americans and almost 6 million Canadians have undiagnosed prediabetes. This is an important consideration when evaluating your client's case. I recommend that questions about diabetes and prediabetes symptoms be included in your Client Intake Form.
The classic early warning symptoms of diabetes include frequent urination and increased hunger and thirst levels.
It is estimated that almost 30 million Americans and almost 6 million Canadians have undiagnosed prediabetes. This is an important consideration when evaluating your client's case. I recommend that questions about diabetes and prediabetes symptoms be included in your Client Intake Form.
The classic early warning symptoms of diabetes include frequent urination and increased hunger and thirst levels.
- In Type 1 Diabetes, these symptoms may develop rapidly over a few months or even a few weeks.
- In Type 2 Diabetes, the development of symptoms may be subtle, taking longer to develop, or absent altogether.
Insulin and the pancreas
Figure 2 - The pancreas is found behind and below the stomach, and is about 15cm (6 inches) in length.
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Insulin is a hormone produced in the pancreas that is essential in regulating carbohydrate and fat metabolism in the body. Insulin acts in the body by taking up glucose from the blood in the liver, muscle and fat tissues, then storing it as glycogen in the liver and muscles.
In essence, insulin removes excess glucose from the blood. If not removed, the excess glucose would otherwise be toxic. Then, when blood sugar levels drop, the stored glycogen is broken down and used as an energy source through a process called glycogenolysis. When natural control of insulin levels fails, Diabetes Mellitus is the result |
Signs and symptoms of diabetes:
We need to distinguish these two terms:
- Signs - Something that you can observe in a person, like red eyes, slurred speech, or cuts and bruises.
- Symptoms - Something that the person complains about, such as thirst, blurred vision or fatigue.
Figure 3 - Some signs and symptoms of diabetes. CLICK the image to enlarge.
Early signs & symptoms of diabetes
What to look for in your client:
EARLY Signs and Symptoms of diabetes can include ALL or SOME of the following:
- Excessive and unusual thirst (polydipsia)
- Excessive and unusual hunger (polyphagia)
- Frequent urination (polyuria)
- Weight change (gain or loss)
- Extreme fatigue or lack of energy; lethargy; stupor
- Hyperventilation or labored breathing (Kussmaul respirations)
- Blurred vision
- Frequent or recurring infections that are slow to clear
- Cuts and bruises that are slow to heal
- Tingling or numbness in the hands or feet
- Trouble getting or maintaining an erection
It is important to recognize, however, that many people who have Type 2 Diabetes may display no symptoms. Medically, this is referred to as being asymptomatic.
That is why they should be checked as part of your case file workup.
That is why they should be checked as part of your case file workup.
Signs & symptoms of a diabetic emergency:
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Diabetic emergencies are divided into two types:
Hyperglycemia, or too much sugar, is a life-threatening complication that typically affects Type 1 Diabetics, although Type 2 Diabetics can suffer from this under certain circumstances. Without treatment, Hyperglycemia can lead to death. Before insulin therapy became available, it was almost always fatal. |
In general, the signs and symptoms of Hyperglycaemia (Diabetic Ketoacidosis) are similar to that of an impaired person. Levels of consciousness or behavior may be altered, and there may be a musty, fruity, alcohol odor on the breath. The ability to follow directions may be affected, as impaired cognitive function is typical.
Insulin shock symptoms (Hypoglycaemia) also display lowered levels of consciousness or confusion, heightened emotional states or violence, and a smell of an unusual odor on the breath.
In general, the signs and symptoms of Hyperglycaemia (Diabetic Ketoacidosis) are similar to that of an impaired person. Levels of consciousness or behavior may be altered, and there may be a musty, fruity, alcohol odor on the breath. The ability to follow directions may be affected, as impaired cognitive function is typical.
Insulin shock symptoms (Hypoglycaemia) also display lowered levels of consciousness or confusion, heightened emotional states or violence, and a smell of an unusual odor on the breath.
Hypoglycemia (Insulin shock symptoms) also displays lowered levels of consciousness or confusion, heightened emotional states or violence, and a smell of an unusual odor on the breath.
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First Responders are taught that the signs and symptoms of each, although initiated by very different root causes, may be difficult to differentiate. Indeed, a standard way of teaching how to identify diabetic disorders in first aid courses is to describe the individuals as having a “drunken appearance.” The first aid strategy when one cannot differentiate the symptoms is to give sugar as a fallback position, as it will immediately assist the hypoglycemic patient, and will not appreciably harm the hyperglycemic person.
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Symptomatic diagnosis (merely looking for signs and symptoms) is virtually impossible, with either blood glucose or blood ketone levels being the only accurate way to assess which condition is present. Ketone level measurement is emerging as the more accurate predictor of early-onset diabetic assessment.
The diagnosis of diabetes:
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Blood tests, blood glucose and A1C levelsDiagnosis of diabetes should be carried out when your client indicates one of more of the symptoms listed above, particularly the early warning signs and symptoms. Remember, they might have diabetic characteristics, and be producing diabetic ketones, without having been previously diagnosed as a diabetic.
Their health care provider will run tests such as:
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The last test, the A1C test, measures an overall indication of diabetes in an undiagnosed person, and poor diabetic management in the diagnosed diabetic. It is one of the most important indicators of diabetes and diabetic management. Any reading over 6.5% indicates uncontrolled or poorly managed diabetes.
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Measuring blood glucose levels:
PRACTICE TIP:
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A modern Blood Glucose Meter, used to monitor sugar levels has a wealth of data captured. Make sure this evidence is preserved.
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Where does this leave your client?
When in doubt, have your client tested for diabetes or prediabetes. Do it sooner, rather than later.
You are specifically looking for the following fact pattern or issues:
You are specifically looking for the following fact pattern or issues:
- A client who answers positively for the signs and symptoms of diabetes, however undiagnosed
- A client with a family history of diabetes
- A client with a history of diabetes that is being treated by diet, oral medications or insulin injections. Check to see how well they are managing their condition with the A1C enzyme test
- A woman who was recently pregnant
- A client who is over age 40
- A client who provides an abnormally high BrAC reading based on their alcohol intake, or
- A client who displays bizarre indicia of impairment, disconnected from a relatively low BrAC reading
- Remember too, that the production of ketones leading to diabetes-type symptoms may be displayed by a person who is fasting, or on an unusual diet (think Atkin's diet). This is another topic for another article in the future...
In Part 2 of this article:
Part 2 of this article will address:
- How your client is affected by hypoglycemia, hyperglycemia, and enhanced ketone levels
- How this affects their observed indicia of impairment
- How their impaired cognitive abilities could affect their performance on the SFSTs.
- How diabetic ketones may affect a breath test on both a fuel cell device, and an infrared evidentiary instrument
- How you can manage these issues in your trial strategy
- What you need in the form of expert evidence
Send me your questions or comments:
Comments and questions will be posted here with their responses:
Comments and questions will be posted here with their responses:
For further study:
- Anderson, Joseph C., Measuring Breath Acetone for Monitoring Fat Loss: Review, Obesity. 23(12):2327-2334, December 2015.
- Bailey, D., Detection of Isopropanol in Acetonemic Patients Not Exposed to Isopropanol, Clinical Toxicology, 28(4), 1990, Pages 459-466.
- Caldwell, J, and Kim, N., The Response of the Intoxilyzer 5000® to Five Potential Interfering Substances, J. Forensic Science 1997;42(6) pages 1080-1087.
- Hak, E.A., The Effects of Volatile Substances on the Intoxilyzer 5000C Breath Testing Instrument, Royal Canadian Mounted Police Forensic Laboratory, Peer-Reviewed Paper for the Traffic Safety 1995 Conference, 1995.
- Jones, A.W., Andersson, L., Biotransformation of Acetone to Isopropanol Observed in a Motorist Involved in a Sobriety Check, Journal of Forensic Sciences, JFSVA, Vol. 40, No. 4 July 1995, Pages 686-687.
- Jones, A.W. & Summer, R., Detection of Isopropyl Alcohol in a Patient with Diabetic Ketoacidosis, The Journal of Emergency Medicine, Vol. 19, No. 2, 2000, Pages 165-168.
- Jones, A.W., Interfering Substances Identified in the Breath of Drinking Drivers with Intoxilyzer 5000S, Journal of Analytical Toxicology, Vol. 20, November/December 1996, Pages 523-527.
- Jones, A.W. & Rossner, S., False-Positive Breath Alcohol Test After a Ketogenic Diet, International Journal of Obesity, (2007) 31, Pages 559-561.
- Jones, A.W., Observation on the Specificity of Breath Alcohol Analyzers Used for Clinical and Medicolegal Purposes, Journal of Forensic Sciences, JFSCA, Vol. 34, No. 4, July 1989, Pages 842-847.
- Laasko, O., Pennanem, T., et al, Effect of Eight Solvents on Ethanol Analysis by Draeger 7110 Evidential Breath Analyzer, Journal of Forensic Science, Sept 2004, Vol 49, No. 5.
- Logan, B, Gullberg, R. and Elenbaas, J., Isopropanol Interference with Breath Alcohol Analysis: A Case Report, J. Forensic Science 1994 Jul:39(4), pages 1107-1111.
- Memari, B., Variables Affecting the Precision and Accuracy of the Intoxilyzer 5000, Florida International University, Thesis for Master of Science in Chemistry, academically reviewed and approved, 1999.
- Norfold, G. & Quartly, C., Volatile Substances and their Potential to Interfere with Breath Alcohol Reading Instruments, Journal of Clinical Forensic Medicine (1997) 4, Pages 21-23.
- Platteborze, P. L., Rainey, P. M. and Baird, G. S., Ketoacidosis with Unexpected Serum Isopropyl Alcohol – Clinical Case Study, Clinical Chemistry 57:10, 1361 – 1365 (2011).
- Puttanna, A., and Padinjakara, R.N.K., Diabetic Ketoacidosis in Type 2 Diabetes Mellitus, Practical Diabetes, Vol. 31, No. 4, February 2014.
