Ask the Expert

| Jan 1, 1991

Q: Are People with Diabetes Prone to Skin Boils?

I have type 1 diabetes. I would like to know why I suffer from so many boils in my groin area.

Kathy Long
Portage, Pennsylvania

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A: Boils are acute, tender, firm, inflammatory nodules in the skin caused by bacterial infection-usually from a staph organism. When superficial, they are a form of folliculitis and when deep in the skin they are called boils or furuncles.

People with diabetes are especially prone to bacterial and fungal infection because of decreased cellular immunity from acute or chronic high blood sugars. The groin area is especially prone to these infections and they can be chronic and recurrent. Perspiration, rubbing, chafing and local factors, especially hygiene, are very important.

Using an antibacterial soap with frequent cleansing and subsequent drying of the area is indicated. One should avoid synthetic garments, use cotton shorts and aerate the area when possible. Antibacterial powders may be helpful after bathing, and topical or systemic antibiotics are indicated when the process is chronic and severe. Acute, warm presses can allow the process to point and then drain spontaneously.

S. William Levy, MD
Clinical Professor of Dermatology
University of California Medical Center
San Francisco, California

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Q: Why are My Morning BGs Higher Than Later in the Day?

I have type 2 diabetes controlled by diet and exercise. I do not take medications. I would like to know why my morning (fasting) blood reading is higher than it is later in the day after I have eaten.

Nancy Potter
Peoria, Illinois

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A: Fasting blood glucose is a measurement of the glucose your liver manufactured during the night. Your dinner or an evening snack the night before does not effect this measurement. The fasting test also provides some indication of your overnight insulin secretion.

Sometimes fasting blood-glucose levels will decline with weight loss. Since you say that your fasting-blood reading is higher in the morning than it is later in the day after you have eaten, I would suggest you speak with your physician about taking a medication. Glucophage is a medication that helps to lower fasting blood-glucose levels by decreasing liver-glucose output. It also reduces cholesterol levels. You might even lose a few pounds if you take this medication.

Please do not consider the use of medication as a failure on your part. It sounds as if you are doing everything that you can to control your blood glucose-by testing, eating healthy and exercising.

Joyce Sokolik, RD, CDE
Santa Rosa, California

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Q: Are We Researching a Diabetes Cure, or Are We Just Researching Research?

We constantly see medical breakthroughs and possible treatment regimens put forward as cures, yet we never hear any follow-up on how these regimens work or do not work. The question I have is, are we really on the path toward a cure to diabetes or are we just funding research for research's sake?

Megan Cybul
West Bloomfield, Michigan

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A: Medical progress usually comes in step-by-step advances rather than dramatic leaps forward. Sadly, companies or others announce many so-called "breakthroughs" and "cures" on the basis of little credible evidence, and such reports often gain media attention. The lack of follow-up reflects the fact that such "breakthroughs" could not be replicated when subjected to testing by other researchers.

When studies supported by the National Institutes of Health (NIH) indicate that something doesn't work, the results are published and widely disseminated. An example is the use of injected insulin for type-1 prevention in high-risk people. Early studies in a small number of individuals suggested this approach might work (Eisenbarth et. al., Lancet, April 10, 1993, p. 927). However, the DPT-1-a large controlled trial-showed that low-dose insulin injections do not prevent type 1 diabetes in high-risk people. This result was presented at a major meeting, is being published in a peer-reviewed journal and was described in some news accounts after a NIH press release. Though we are disappointed with the trial's outcome, letting people know negative results is important so that ineffective measures are not widely used.

The National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) is vigorously exploring every possible avenue toward a cure, giving highest priority to those routes that offer the most hope based on current knowledge.

There is great optimism about islet transplantation inspired by the pioneering work of the Edmonton Group published last year in the New England Journal of Medicine and in a follow-up report of the 12 study subjects published in Diabetes last April. The Edmonton Protocol is being replicated on a wider scale with NIH and JDRF support. We have no guarantee it will hold up under a wider study. If it does, we will still need to develop alternative supplies of islets for the hundreds of thousands of people who need them as well as alternatives to anti-rejection drugs.

This is just one avenue of research we are supporting on the path toward a cure.

Allen M. Spiegel, MD
Director National Institutes of Diabetes and Digestive and Kidney Diseases
National Institutes of Health

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Q: What is Gastroparesis and How Can I Control It?

I have gastroparesis and type 1 diabetes. I would like to know what I can do to control my blood sugars and keep from getting bloated. I am on the pump and cannot accurately predict the effect foods have on my body. I also seem to have a bad problem with bloating. I can go from a size five to a 10 in one day.

R. Ramirez
California

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A: Gastroparesis, or a partially paralyzed stomach, is commonly found in people with diabetes who have experienced elevated blood sugars for a number of years. In advanced stages, it can cause symptoms such as early satiety and bloating, nausea and vomiting. In the early stages, it is only discernable by its erratic effects upon blood sugar due to unpredictable stomach emptying.

Gastroparesis is very difficult to treat, but it can be rendered less severe by a number of measures used simultaneously.

Since you appear to have a relatively advanced condition, severe dietary intervention is warranted. This includes a very low-carbohydrate diet with total elimination of high-fiber vegetables such as salads, broccoli, etc. Protein foods should be limited to fish, eggs, cheese and ground meats. Even better would be a liquid or semi-liquid diet such as baby food and drinks made from egg-white protein.

There are a number of other approaches to speeding stomach emptying that should be used in addition to the dietary changes. These include drinking two glasses of water with each meal, taking certain digestive enzymes while eating, doing special exercises and chewing gum after meals, etc. Although there are some medications that can improve stomach emptying, none of them are effective for advanced cases like yours. An especially effective enzyme is betaine hydrochloride with pepsin. It should be taken as three capsules while eating, never on an empty stomach. It should not be used by people who have ulcers or gastritis.

More details can be found in my book "Diabetes Solution," which is available at most bookstores and at www.amazon.com. A chapter is devoted to the treatment of gastroparesis. It also covers the proper use of insulin for people with gastroparesis. One of the most important tips is to never use lispro insulin (commonly used in insulin pumps) to cover meals. It works faster than the stomach can empty food.

Additional guidelines appear in a previous issue of Diabetes Health entitled "Innovative Therapy Helps Man Overcome Diabetes Complications," (October 1999, p. 29). This article is archived on the Web site www.diabetes-normalsugars.com.

Richard Bernstein, MD, FACE, FACN, CWS
Mamaroneck, New York

Dr. Berstein has had type 1 diabetes since 1946. After learning how to normalize his blood sugars in 1970, it took 13 years for his gastroparesis to slowly resolve. His advice is considered to be outside of the mainstream. He has criticized the Standard Diabetes Care Guidelines as being ineffective.

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Q: What Can I Do About Fat Build-Up at Injection Sites?

I have been a type 1 for 38 years and have excess fat at the site where I take my shots.

Rotating does not help at all. When you take shots for so many years, there are only so many places to take your shots before you have to start over. It is especially bad in my arms and it is hard to find clothes to fit over them.

Is there anything that can be done about this, or is plastic surgery the only solution?

Dean Ross
Internet

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A: We usually call what you are describing lipohypertrophy. It can be unsightly, annoying and somewhat dangerous. Insulin injected into the areas of lipohypertropy can be absorbed more slowly, leading to both increased blood sugar right after a meal and low blood sugar hours later.

Lipohypertrophy occurs in more than 25 percent of patients with type 1 diabetes. It is usually attributed to impure insulin (rare now) or not rotating sites. Interestingly, a recent study at 23 sites in Europe showed that reusing insulin syringes and pen needles led to increased lipohypertrophy.

Treating it can be difficult. A recent study shows that switching to lispro insulin may help. The best treatment is to avoid repetitive injections into the same site and particularly avoiding the areas of lipohypertrophy. I would suggest that you concentrate your injections in the abdomen. Buy a piece of mesh, like that used for hooking rugs, cut it to fit your abdomen and use it to locate your injections, so that you avoid sites that you have used in the past week or two.

Barry H. Ginsberg, MD, PhD
VP Medical Affairs
Becton Dickinson

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Q: Should I Be Concerned with After-Meal BG Spikes?

How important are after-meal (two-hour) glucose readings that are occasionally in the 180 to 200 mg/dl range if your A1c range is normally between 5.4 and 5.8%?

Mark Holmes
Troutdale, Virginia

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A: There is currently a vigorous debate regarding the importance of after-meal glucose "spikes." Some of us feel that they should be kept to a minimum because there are biochemical reasons to think they may contribute to diabetes complications.

For example, the aldose-reductase pathway enzymes are "turned on" when the glucose levels reach 180 mg/dl or more. This pathway is thought to be very important in the development of some diabetic microvascular complications.

Epidemiologic data indicate a dramatic increase in retinopathy and kidney disease associated with after-meal BGs of 180 mg/dl or greater and the increase in macrovascular disease (heart attacks and strokes) increases at even lower levels.

Dr. Lois Jovanovic's recent paper shows that when the fasting blood sugar (FBS) is over 140 mg/dl, it is the major contributor to an increased A1c, but when FBSs are better, the after-meal glucose is the main determinant of A1c. Remember, an A1c of 5.4 to 5.8%, although within the "normal" range, is still higher than the non-diabetic average (which is 5% on the standardized lab value used for the DCCT and other major studies).

Another recent paper published in the December 2000 issue of Diabetes Care (p. 1830) found that plasma-glucose spikes were more strongly associated with narrowing of the arteries than were fasting BGs or A1c levels.

Levels such as yours should be relatively easy to correct using some dietary changes and possibly adding an alpha-glucosidase inhibitor like Precose or Glyset.

Nancy Bohannon,
MD, FACP, FACE
Monteagle Medical Center
San Francisco, California

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Q: Is Injecting Air Bubbles Dangerous?

What are risks of inadvertently injecting air bubbles from a needle?

David Craycraft
Laytonsville, Maryland

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A: The main risk is that you are replacing insulin with air and, therefore, underdosing. If that is not a problem (i.e., you have compensated for it) then there is no risk when the injection is given under the skin. You may be able to feel the air, but it will go away in a few minutes. Air should never be injected intravenously.

Barry H Ginsberg, MD, PhD
VP Medical Affairs,
Becton Dickinson
Franklin Lakes, New Jersey

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Categories: A1c Test, Blood Glucose, Blood Sugar, Diabetes, Food, Gastroparesis (Digestion Problems), Glucophage, Insulin, Insulin Pumps, Lipohypertropy, Losing weight, Nutrition Advice, Pens, Skin Care, Syringes, Type 1 Issues, Type 1 Issues, Type 2 Issues


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