Letters to the Editor
RN Reads It Regularly
I am always happy to see Diabetes Health in my mailbox. I feel like I have to read it completely before I see my next patient-or staff nurse-or doctor who has questions about diabetes. Thanks so much!
Mary Fiolkoski, RN, CDE
Give Me Your Sources
I have some questions about your article, "Beyond the Pain: Causes and Treatments of Neuropathy," by Pam Weiss. The article states that "magnesium supplements are highly recommended for the treatment and prevention of neuropathy." I have not heard this-what is the source? The recent ADA Consensus Statement (Diabetes Care, August, 1992) did not recommend magnesium supplementation in that manner. I also wonder about the use of B vitamins, since it has been documented that B-6 in doses even as low as 75 mg/day can cause neuropathy (ActaNeuroligica, Scandinavia, 1987). And finally, I am not familiar with myo-inositol being a B-vitamin, nor the fact that vitamin E is helpful in neuropathy. Could you please supply references for these?
Joanne Cybulski, MS, RD, CDE
[Thank you for your letter in response to my article, "Beyond the Pain: Causes and Treatments of Diabetic Neuropathy." As I am sure you are aware, nutritional supplementation is a highly controversial topic. During the conference for Diabetes Educators held in Atlanta this past August, two papers were presented by highly regarded professionals on the role of micronutrients and diabetes. One paper, presented by Keith Campbell, a pharmacist, professor of pharmacy at Washington State University, and diabetes educator, recommended specific vitamin and mineral supplements for people with diabetes, including 400 mg of magnesium, 2 mg of B-6 (as well as all of the other B vitamins), and 1000 mg of Vitamin E. In a second paper, presented by Marion Franz, MS, RD, CDE, from the International Diabetes Center in Minneapolis, the opposing view that "there is no justification for routine prescription of vitamin and mineral supplements for people with diabetes" was presented.
So even among professionals in the field, there is not consensus about the need for or benefits of nutritional supplementation. Given that, I attempted to present information in my neuropathy article that, while not necessarily conclusive, was up-to-date, had multiple references in the medical literature, and was supported by key professionals in the field.
The statement that "magnesium is highly recommended..." is based on research findings (by Dr. Arshag Mooradian, co-author of a comprehensive study on diabetes and micronutrients, and Dr. Samuel Malayan at the University of California, Los Angeles), that link magnesium deficiency to diabetes and hypertension. This research is supported by Dr. Alan Marcus, an endocrinologist and member of our medical advisory board, who recommends magnesium supplements to his diabetic patients.
The information provided about myo-inositol is referenced from research in Clinical Diabetes (July-August 1991). It also came highly recommended by Dr. Aaron Vinick, M.D., Ph.D., from the Diabetes Research Institute at Eastern Virginia Medical School. Dr. Vinick is a preeminent figure in the field of diabetes and neuropathy who has conducted extensive research, and published widely. In interviewing Dr. Vinick, he admitted that myo-inositol has not yet received sufficient financial backing to "scientifically prove" its effectiveness, but also reported that he recommends and uses it with the hundreds of neuropathy patients he sees at the Research Institute.
The information about Vitamin E as an aid in restoring nerve function is referenced to research in both The New England Journal of Medicine, and Lancet. It is also supported by Dr. Marcus, as well as by numbers of our readers who have reported its benefits to us.
Your point about vitamin B-6 is an important one. The USRDA for vitamin B-6 is 2 mg. And it is true that "therapeutic" (meaning more than three times the USRDA) and "mega" (meaning more than ten times the USRDA) doses of B-6 have been found to have adverse effects. It was not my intention in the article to make specific medical recommendations about taking B or other vitamins. Such recommendations should always be made on a case by case basis by a qualified medical professional. I apologize for failing to be more specific in my discussion of B vitamins, and thank you very much for bringing this point to my attention.
As a diabetic of 21 years myself, I am often frustrated by the lack of information available about so-called "alternative" therapies. While I understand the need to be cautious about products advertised as panaceas, I also feel that it is important to make information accessible that may not be available through the ADA, but which may be helpful to people struggling with an extremely painful, often debilitating condition.
My article was written in response to the numbers of letters we have received from our readers asking us to publish what we know about neuropathy. None of the information in the article was meant to substitute for professional medical advice. Rather, the information is intended to help educate people with diabetes so they are better able to ask informed questions, and work with their medical advisors.
Again, thank you for taking the time to write with your concerns, and share information. We greatly value the opportunity to use the newspaper as a forum to allow people like yourself to share your expertise.-Pam Weiss]
Type II & Insulin Therapy
My discovery of your publication has given me a great lift. You seem to have the courage to break the mold and let some light in on diabetes. Well, I have something for you to consider.
The Diabetes Control and Complications Trial (DCCT) has demonstrated once and for all that high levels of excess glucose do the damage that causes diabetes complications. No longer any argument about that.
So why does everyone continue to put people with Type II diabetes through the farcical and tragic set of hurdles that were constructed before there was adequate information?
The newly diagnosed type II first goes on a diet and increases exercise to control blood glucose levels. This is partially based on the conception that all type II's develop because of obesity or weight gain. More likely, as in my case, weight gain began as excess glucose was deposited as fat because of insufficient or ineffective insulin.
When this program fails, sulfonylureas of various generations and dosages are prescribed to force the malfunctioning pancreas to greater exertion. When the pancreas quite properly refuses to perform under such duress, then and only then will most physicians advise the frustrated and confused type II that a program of self-administered insulin will, if properly managed, lower their blood glucose levels to near normal. Diet and exercise are, of course, part of that management.
For the first time the person with type II diabetes has enough insulin when it is needed to control blood glucose levels, relieve the tingling and pains in the extremities, and feel really well.
Why couldn't the insulin and the training to use it in self-care be made available to those type II's who need and want it at the beginning? This would restore them to control much earlier and avoid the long years of damage caused by excess blood glucose as each traditional step fails, as fail it must for huge numbers of us.
A really clever way to contain the cost of blindness and amputations in the 90% of people with diabetes who are type II would be to practice prevention by making the information, insulin, and education available to us when we are diagnosed, not after the damage is well begun, fighting a disease which is relentless in its progression without prevention and control.
We need to accept the findings from the DCCT on the causes of diabetes complications and radically change our approach. Early education and availability of insulin therapy for type II diabetes should be made available to those who would welcome better control earlier.
Reading your comments convinced me that you were fed up with the wrong-headedness of the early advice and treatment after your diagnosis with type I diabetes. Perhaps you could raise this issue among your readers and the diabetes treatment specialists. If I had to guess, people with diabetes would probably accept this sooner than the professionals.
Los Angeles, CA
Who is to Blame?
I saw an Anne Landers column titled: "Diabetics who won't take control of the disease have themselves to blame." I feel that while that may be partially true, there are many people with diabetes who do take control of themselves, and they still end up getting complications. I think it's very unfair to put that in the paper; it makes all people with diabetes look bad. I realize I should be writing to Anne Landers, but I thought others might want to write to Anne Landers, as well.
Virginia Beach, VA
Just Say 'Sugar-Free'
I do alot of traveling, and I always ask if they carry sugar-free products (like syrup, jam, etc.) before going into a restaurant or hotel. People with diabetes don't ask for sugar-free products often enough; I urge all people with diabetes to ask for them so that if they don't already carry them, they will in the future.
I was diagnosed with diabetes in March of 1974. For a long time I went into a denial period, thinking that the doctors and nurses mixed up my reports with someone else's. All of a sudden, I grew up and accepted my diabetes.
I would like to thank your newspaper so very much. Diabetes Health has a lot of interesting reading regarding: everything you want or need to know.
I look forward to each copy and will always enjoy your comments. Please include more articles on diabetes and pregnancy. I am 36 years old and my husband Bob and I want children.
One Happy Pumper
I am thankful for your newspaper, it is a help to people with diabetes. I have had diabetes for forty years.
I am writing to tell you about the miracle that happened on Monday, November 8th at 9 am. The technician Bell Wooster started me on an insulin pump. Within a few hours I felt a new strength and energy. Even my mind felt positive, happy, and stress-free.
My blood sugars had been under good control on insulin injections and Micronase, but I suffered constantly from mild headaches and other symptoms.
All I can say is that a miracle has happened to me. If I hadn't gotten an insulin pump, I would never have found this miracle that has made my life wonderful.
I called a doctor who had treated me in the hospital 30 years before. It had been 5 years since I had seen or spoken to him, so I called him and asked "do you remember me?" He said yes, and I shared with him what one day on the pump was like, because he also has diabetes. He said "God gives wisdom to doctors," and he told me that there are only 1000 people on the pump in Orange County, California, that I was 1 in a thousand.
I write this letter in the hope that even one reader will be encouraged by reading this in your publication. Thanks to Diabetes Health for helping people with diabetes.
Santa Ana, CA
Insulin Adjustment Tips
Here is a success formula that works for me, some of your readers may also appreciate it.
Type-I Insulin Dose Adjustments
By: Ronald Elliot
I have suffered from diabetes for thirty+ years, from the age of twelve. Through the decades, valuable information eventually seeps through the maze and I will share one piece of my collection with you today.
It is very simple. One unit of Regular insulin lowers your blood glucose (BG) level by approximately forty (40) blood glucose points. In other words, +1 r = -40 BG.
Imagine you take your evening test with a reading of 140 BG. Let's say your normal evening insulin dose equals six units of long lasting NPH and seven units of Regular insulin (6 n, 7 r).
Since an ideal BG reading equals eighty (80 BG), the idea is to adjust your normal dose by adding enough Regular insulin to bring your current reading of 140 BG down to 80 BG so you may eat your normal calories without raising your blood glucose to unacceptable levels.
140 BG + 1r unit =
140 BG - 40 BG = 100 BG
100 BG + 1/2 r unit =
100 BG - 20 BG = 80 BG
Therefore, in the above example, add 11/2 r to your normal dose which, in this case, totals 6 n, 8 1/2 r instead of 6 n, 7 r.
Of course, since every case of diabetes differs slightly, some type I (insulin dependent) diabetics are more insulin tolerant than others. Experiment cautiously.
May your lancet work the first time, may your needle be sharp, and may your channel always be clear.
San Francisco, CA
Wants More Insulin Info
I am very interested in Scott King's reference to 1) Ultralente insulin and 2) Barry Ginsberg's article on adjusting insulin.
Where could I obtain additional information?
I've been insulin dependent for 38 years and have never been satisfied with my glucose control.
Thank you for a very informative publication.
[Editor: Dr. Ginsberg's articles can be found in back issues of Diabetes Health; just look for our order form on page 15 of the January, 1994 issue. If you would like an example of the benefits of Ultra-lente insulin, just read the next letter. For more information about Ultralente and how to begin using it, consult you doctor.]
I'm writing to let you know of one very positive benefit I derived from reading your newspaper.
When previous oral medications, diet, and exercise programs failed to control my blood glucose level in June, I began insulin treatment. After trying several different schemes, my doctor and I settled on two mixed doses of NPH and Regular, one before breakfast and the second before supper. Of course the diet and exercise continued.
Blood glucose testing and graphing revealed that a high reading occurred after lunch. A pre-lunch dose of regular covered that. I then began having low blood glucose readings and hypoglycemia in the afternoon and sometimes during the night.
I read an article in Diabetes Health on the use of Ultralente for a basal dose and regular three times a day to cover meals. My doctor was reluctant to start me on beef Ultralente, but we found that Humulin Ultralente by Lily was now on the market.
Bingo! Gone is the hypoglycemia and anxiety during the night. No longer must snacks chase the insulin peaks NPH caused. Hunger is no longer a problem.
My appreciation of your paper is based on real benefits derived from the information you provided which helped me achieve better control and worry-free self-care.
Los Angeles, CA
Just Keep It Coming
I really enjoyed the neuropathy article, it had more depth and perception than any article I have ever read on the subject. The only question I was left with involved dosages. Although there is a dosage of around 400 IU's of vitamin E recommended, I was curious about the studies that were done with magnesium. What kind of doses are generally recommended in those studies?
I like your newspaper better than any other thing in the field. I don't mind whether it comes out bi-weekly or bi-monthly or what, as long as you keep producing it.
Jeffrey S. Davis
[Editor: Thank you for your support! In answer to your question about dosages, Dr. Alan Marcus recommends taking 250 mg once a day on an empty stomach (1 hour before or after a meal). You shouldn't take magnesium with calcium (many multivitamins contain both) because the body will absorb the calcium instead of the magnesium. Calcium should be taken with meals.]Click Here To View Or Post Comments