Questions and Answers
Q: I am a mother with type 1 diabetes and read with interest the "My Own Injection" column in March 1998 ("The Diary of a Diabetic Dad") describing Scott King's trials and tribulations as a dad with diabetes.
I too did not give my daughter cows' milk during the first year of her life. I have a question regarding the chewable vitamins with antioxidants that Mr. King gives his son.
I looked in pharmacies at the over-the-counter children's vitamins and did not see any mention of antioxidants. If there is any possibility that this could prevent or delay the onset of diabetes in my daughter I want to give them to her ASAP!
Also, if there are any other prevention measures that you know of, or where I can get some information, I would truly appreciate it. I am also interested in prevention trials for type 1 diabetes sponsored by the NIH and am considering enrolling my daughter when she turns three.
A: Internet reader Sonia Cooper responds:
As a layperson, I am happy to provide you with my opinions on prevention. My son, who is almost eight, developed diabetes at age one, so when I became pregnant with my third child, I searched for a trial. There is a trial in Denver called DAISY for children three and under who have a first degree relative with diabetes. You can only participate in their trial if you are willing to visit the Barbara Davis Center at least once each year. There may be other studies following children from birth, but this is the closest one to our home.
I started participating while pregnant. When my daughter was born, we found from an umbilical cord blood sample that she had the same genetic combination of alleles as her diabetic brother (DR3/DR4). Most children will not have this high-risk combination, and intervention strategies are not really warranted for them yet. Therefore, my first piece of advice is get your child's allele combination documented. If your child has a low risk or protective allele combination (this is the most likely outcome) then you can rest a bit.
No matter what the allele combination, your child can be tested to see if she is autoantibody positive. If your child has a low risk combination and is negative for the autoantibody markers, she has a very low risk of getting type 1 diabetes. If she tests positive for antibodies, she will be put into a trial for oral or injected insulin to try to delay or prevent onset.
If you have a child with the high risk combination, you can supplement with antioxidants and withhold cow's milk until one year of age.
Withholding cow's milk and banking cord blood (for possible future use) are good precautionary measures. Still, none of these actions constitutes much of an answer for sidetracking this autoimmune disorder.
Our family studied the work of the Israelis, Canadians and others on using the Bacillus Calmette-Guerrin (BCG) vaccine as a preventative measure. If your child is already autoantibody positive or is a newly diagnosed diabetic, BCG will not work, according to well documented U.S. studies. It only appears to be effective if you give it prior to becoming autoantibody positive. The bad news is that the highest risk (DR3/4 allele combination) kids start developing signs of autoimmune problems by age three in about half the cases. After the markers show up, it looks as if the BCG won't work (my opinion). It also appears that a "booster" of BCG may be needed by age four or five, but the trials have not started on this yet. There are some risks associated with BCG. It is the vaccination against tuberculosis and is available now, but usually only after signing a lengthy release form.
Anyhow, if you want to take action, the first thing you should probably do is find out if your child has a high risk genetic combination. My oldest son is at low risk, and we never worry. I hope that your child is also at low risk. You should still enroll in the studies and participate regardless of your child's risk, though, as it may help others.
I also encourage you to study and read everything you can about this and make your own decisions. There isn't one definitive published answer yet regarding prevention, but if you read what is available, I hope you will be as optimistic as I am that we have the potential to start intervening on behalf of the highest risk children by the year 2000.
I strongly believe that the first person to correctly articulate a protocol for intervention will be credited by history for eliminating type 1 diabetes, the most common chronic disease of children today, an accomplishment which would rival that of Dr. Jonas Salk's vaccination for polio in 1954. Like Dr. Salk, this researcher should also be awarded the Congressional Gold Medal. I passionately hope that the race is on.
For more information on this process you can contact Sonia Cooper at firstname.lastname@example.org
A: Dana Arnold, RD, CDE, re-sponds:
Cow's milk is not recommended for any child under the age of one because of frequent allergic reactions and decreased digestibility. I recommend breast feeding, however, during the first year of life rather than using a baby formula because of the immune properties contained in breast milk. These immune properties could potentially have a protective effect against type 1 diabetes by bolstering the immune system, not just during breast feeding, but beyond that time as well.
Regarding your question on children's vitamins, antioxidant vitamins will not be specifically listed as such on a vitamin label. Antioxidant is a term that describes a substance that inhibits the oxidation of other compounds. Some common antioxidant vitamins and minerals include vitamins A, C, E and the mineral selenium. I checked the labels of a few children's vitamins and found that they all contain vitamins A, C and E, but they do not contain minerals. This is likely due to the lack of research on excess supplementation in children. For that reason, I recommend avoiding separate supplements containing antioxidants for a child but I recommend giving all children a children's multivitamin in addition to a healthful diet rich in vitamins, minerals and fiber.
Dana Arnold MS, RD, CDE
Daly City, Calif.
Insulin Down Under
Q: I've had type 1 diabetes for 28 years. Travel is part of my new job. My first trip is to Australia - a 15-hour time difference from here. I do not have a clue how to handle my insulin. How should I adjust my dosage over such a large time difference? (I use Humulin insulin. My dosage is 10 units of NPH and five units of R in the morning and five units of NPH and five units of R at dinnertime.) I'm also concerned about my body clock and fighting exhaustion, which throws off my blood sugar control. What should I do?
A: If you are going to be trav-eling to Australia, first remember to pack sufficient insulin and other diabetes supplies in case the insulin available in Australia is different in name and strength from what you are currently using. Syringes, blood glucose monitoring equipment, ketone testing strips and glucose tablets or raisins should also be in sufficient quantity to cover your needs for the duration of your trip as well as for unplanned delays in your plans. Remember to carry these supplies on board the airline to avoid freezing your insulin. It's also wise just in case the airline loses your luggage.
When traveling across more than five time zones, keep your watch on "home time" for the first 24 hours or until you arrive in Australia. Your elapsed travel time should be approximately 22 hours plus any layover. I would therefore advise you to space your usual insulin doses 10 to 12 hours apart according to the time schedule of your flight. As you will be gaining additional hours traveling east to west, you will need a supplemental dose of regular insulin once you arrive, to hold you until your evening insulin dose is due. You will also be eating an additional meal during this time period and may need short-acting insulin to cover it. Please discuss your travel and arrival times with your physician so that this dose can be determined.
Traveling west to east, you will likely lose hours, depending on the travel times. I again recommend that you keep your watch on Australia time until you arrive home. Take your usual dose for the first part of your flight and your next insulin dose 10 to 12 hours later. Your second travel day will be shortened, possibly by six or more hours, as determined by your arrival time. Therefore, take approximately a third less of your second NPH dose. Once again, discuss your travel and arrival times with your physician to determine which NPH dose will be affected.
As for fighting off exhaustion and jet lag, I would recommend drinking at least 16 ounces of water as well as avoiding caffeine and alcohol during your flight. Get some exercise periodically during the flight, even if you just walk the aisles. This will help you get to sleep while flying, improving your chances of feeling somewhat rested when you arrive. Then try to have a small meal or snack and stay awake until close to the usual bedtime of your arrival city. You should hopefully feel close to normal by the next morning. The same holds true for when you return home.
No long distance travel is without trial and tribulation, but hopefully this will make the ordeal somewhat more bearable.
Phyllis Furst, RN, MA, ANPC, CDE
North Shore University Hospital
A Vitamin a Day
Q: I am 32 years old and have been insulin dependent for the last 25 years. I am on the insulin pump and it seems to be working fairly well. I was wondering if you could provide me any additional information on vitamins that help lower BG levels. I would like to start taking vitamins anyway, for general health purposes, but I want to make sure that whatever I take does not interfere with my diabetes in a negative way. I have read a little about chromium, but that is it. Please advise.
A: First of all, I am glad to hear that you are doing well with the insulin pump - that is a great achievement. As for added vitamins in your health plan it is still the stance of the American Diabetes Association as well as the American Dietetic Association that when eating a healthy diet one should take no more than a regular multivitamin. What I mean by regular is one that does not exceed 100 percent of the USRDA for any particular nutrient. Remember when one takes megadoses of any vitamin it is similar to taking a medication. Vitamins will effect the body's function both in positive and negative ways. Check with a health care provider before you make any changes.
As for chromium, this mineral has received a lot of press. However, there is no real evidence that chromium improves diabetes management in those that are not chromium deficient.
If you are considering taking a particular nutrient because a company is making impressive claims, ask to see their research and look at what these claims are based on.
If I was to recommend any addition in one's diet it would be to make sure one is eating a variety of foods and getting enough of those nutrients for which there is substantial evidence of their health preventative power. For example, most of us do not get enough fiber on a daily basis, and lack of this nutrient has been associated with many chronic diseases time and time again. One should aim for 25 to 40 grams a day, i.e. 10 grams per meal.
The vitamins that have substantiated health claims associated with them are listed below. So check your multivitamin to see if they include the list of favorites.
- 400 mcg of folic acid
- 400 IU of vitamin D
- 25 mcg of B-12 (if you are 50 or older)
- 300 mg of calcium (if you don't consume at least three lowfat dairy, calcium fortified or soy based products a day).
- 50 to 100 IU of vitamin E
For more information the ADA has published a position paper on vitamins and minerals which you can find by accessing www.eatright.org and search under positions.
Beth Beller, CDE, RD
Jamaica Estates, N.Y.