Questions and Answers
I thought Daniel Trecroci's foot care feature in the February issue ("Does the Shoe Fit? Important New Products for the Diabetic Foot") was very well written and organized. It is always good to express opinions from a variety of specialties.
In contrast, I must admit Dr. Neil Scheffler feature ("Keeping Feet Healthy and Safe") didn't seem up to par with the rest of your publication. I am the sole podiatrist for Bemidji Area Indian Health Service, serving a population of 78,000 on thirty-three reservations, and it is important for me to offer empowerment rather than to doom people. It most frustrating to undo incorrect advice given to patients by other care providers, television programs and printed materials. When Dr. Scheffler advises patients not to "soak their feet," patients often misconstrue that to mean "don't get your feet wet" and the educator is challenged to convince those patients that it is not only okay, but of paramount importance to wash your feet with soap and water daily. It would be better to explain that soaking the feet, i.e.. sticking your feet in real hot water for 10 plus minutes, isn't recommended because it can dry or burn the skin if your feet are neuropathic. However, for diabetic feet that have a healthy circulation and sensation, "soaking" may be the best way a person can clean their feet.
Also, one quick note about Scheffler's article, "Preventing Charcot Foot Deformity," Since amputation is a common occurrence for a mismanaged neuropathic foot, it is my opinion that surgical correction of these feet should be reserved for selected patients who cannot be managed successfully with aggressive non-surgical measures such as the patellar-tendon brace with custom-molded footwear.
I hope I don't come off as some "know-it-all" because I always learn a great deal from Diabetes Health. You do a fine job of informing the diabetes community by explaining the reasons behind the advice, enabling the patient to understand concepts at a fundamental level. Instead of just listing the do's and don'ts, Diabetes Health usually demonstrates why certain behavior can help or hurt a situation.
DPM PHS/IHS Hospital
Diabetes Resource Center
Cass Lake, Minnesota
Novo Discontinues Pork
It comes as no surprise that Novo Nordisk is planning to finally remove their last remnant of animal-derived insulin. (And good luck to that significant number of people who will now have to switch to a form of insulin with a different pharmacokinetic profile and perhaps an alteration in hypoglycemic awareness.)
Medical journals are full of ads by pharmaceutical companies encouraging physicians to "individualize treatment," whether it be for high blood pressure, high cholesterol, chronic bronchitis, or pneumonia. Different companies compete with one another and try to encourage physicians to use their particular product. Managing diabetes, one of the most complex and challenging of all medical conditions, ironically has been made significantly more difficult for many patients since the withdrawal of animal insulins. Managing diabetes does indeed require a highly individualized approach, and I find it shameful and offensive that two giant pharmaceutical companies like Eli Lilly and Novo Nordisk, with the acquiescence of the medical profession, should cursorily withdraw a significant treatment option for a great many individuals.
Those who really matter are shareholders. Economics will prevail!
Andrew Farquhar MD
Kelowna, British Columbia, Canada
It was 77 years ago that producers developed the natural animal insulin to a purity level which saved million of diabetic lives. Today the primary goal is the happy life of the shareholders.
We think that we have strayed too far from the mission of the American Diabetes Association "to improve the lives of all people affected by diabetes." We hope that in all countries, free choice of insulin, including that of natural animal-source insulin, should be regarded as the top goal of life quality for people with life-long insulin treatment.
Arthur Teuscher, MD
Medical Faculty, University of Bern, Switzerland
Reaction to Treatment Centers Article
The treatment center article in the February issue ("Treatment Centers Provide Many with Prescription for Control," p. 24) was well written and very interesting, but left me somewhat depressed. It seems that if you are very rich, you can learn to stay well. Those of us on Medicare or with HMO's don't stand a chance.
You reported in the February 2000, edition of Diabetes Health that a 1994 Pritikin center study showed that 76 percent of those participants who were controlling their diabetes with meal planning and exercise "went home with the diagnosis that they no longer had diabetes." I believe this points to the effectiveness of meal planning and exercise, especially with weight loss, in controlling diabetes but does not represent "cured." What would a follow-up study on this same group of people show today? If these people were challenged with a glucose load would they continue to have normal blood glucose levels? Diabetes is a progressive disease whose complications may be, to a large extent, prevented by normalizing blood glucose levels.
However, there is no known cure for diabetes today by any specific treatment program.
Eloise M. Hill, MN, RN, CDE
Pros and Cons for Low-Carb Diets
I was very unhappy to read your low-carb article. I will not be able to recommend your magazine in the future. Nurses should not be your source for nutrition. You need to give nutrition information from valid sources.
A 25-year Diabetes Education RD CDE
The article written by Juliette Chen and Sharon Mulry in the February issue of Diabetes Health, based on a presentation of Joy Pape, RN, CDE, illustrates the irresponsibility of a registered nurse whose lack of knowledge and full understanding of medical nutrition therapy for patients with diabetes is well exposed.
Pape, unfortunately, like so many in the health care profession who deal with the treatment of diabetes, takes a myopic view which focuses only on blood glucose levels, rather than the complete medical picture of the patient. She ignores basic nutrition principles such as meeting fundamental nutrient needs of the patient. She also ignores well-documented and scientifically valid diet therapy in favor of "quack treatments" which are neither scientifically valid, and are loaded with hazards which promote the long-term health consequences associated with high-fat/protein diets.
It is my hope that Pape, and those who share her popular, though scientifically unsound approach, will either educate themselves to appropriate forms of medical nutrition therapy, or as responsible professionals do, make the appropriate referral to a qualified and knowledgeable Registered Dietitian whose practice would be based on available sound nutrition science.
Jo Scott, RD
Lifestyle and Health Educator
Coordinator of Outpatient Nutrition Services
Panorama City, California
I am writing in regards to the article on high-protein, low-carbohydrates that was written by Juliette Chen and Sharon Mulry for the February issue of Diabetes Health. Nowhere are scientific studies referenced to show that these diets work. It is usually based on testimonials and personal anecdotes.
We know that good blood sugar control prevents complications, but how will high-protein, high-fat diets help the 70 percent of all diabetics who die from heart disease and clogging of the vessels to our extremities? It has also been shown that foods high in animal products lead to other major health problems, including osteoporosis and cancer, which are a big concern to me.
My idea of a healthy diet is getting all the nutrients I need from food sources and having my digestive system work as it was designed. Beyond that, I use medications and exercise to help me control my blood sugar.
As a CDE, I could not, in good conscience, promote the latest fad diets just because some people with diabetes are choosing them.
Anne Sumida, RN, CDE
Diabetes for 37 years
Editor's reply: We asked Joy Pape, RN, CDE, to reply. The article was based on Pape's speech which she delivered at the 1999 American Association of Diabetes Educators annual meeting.
I would like to thank you for reading and responding to the article on lower-carbohydrate diets. The fact that many of our patients are trying these very popular diets inspired me to travel cross country to interview the authors of the more popular books advocating lower-carbohydrate diet (see the Feb. Diabetes Health, page 33). I also spoke to patients and looked at their charts to see the validity of the claims and the safety and how these plans were actually carried out. Most of my findings are in the article.
I too had concerns about these lower-carbohydrate programs because they were so opposed to what I had been taught as an RN and CDE (Board Certified Diabetes Educator).
I was taught that there is much more to diabetes care and management than glycemic control. I think the DCCT and UKPDS (as well as other studies) have clearly showed us that. We must look at weight, blood pressure, lipid profiles, kidney function, as well as other parameters. We are also taught that Medical Nutrition Therapy (MNT) is not the only treatment for diabetes, but a very big part of it. First-line therapy for people with type 2 diabetes is usually MNT and exercise. We then add medications if needed to bring blood sugars into target range. When speaking of MNT, we are taught that there is no longer one ADA or "diabetes diet." (In 1994 the American Diabetes Association backed away from recommending a diet, and encouraged all with diabetes to get individualized guidance from a registered dietician.)
The ADA now states the goals of MNT are to
- restore and maintain as near-normal blood glucose levels by balancing food, medications and activity;
- provide assistance in obtaining optimal lipid levels (cholesterol, triglycerides, LDL, HDL);
- provide adequate calories for obtaining or maintaining reasonable weights for adults;
- treat the acute and chronic complications of diabetes;
- improve overall health through optimal nutrition.
As reported in the lower-carbohydrate article, what I saw on my trip was in keeping with these goals.
I saw that some people lost weight, and I saw improvements in glycemic control, lipid profiles, blood pressure, and kidney and nerve function as well.
If we look at biochemistry, rather than just looking at food groups we can better understand how this system works.
The lipid profile usually seen in people who have diabetes is a increased triglyceride and a decreased HDL (the good cholesterol). Recent studies are showing us that this profile is atherogenic, or causes heart disease. People who follow these lower-carbohydrate diets are finding that their triglycerides are decreasing and their HDL is increasing. This is a positive finding.
Many people speak of the long-term detrimental effects of these lower-carbohydrate plans. I am not aware of any studies that prove this. If you know of any, I would be happy to hear about it. We as professionals need to be open and informed, and not be afraid when our patients choose another way.
Joy Pape, RN, CDE
I was very pleased to see that you have devoted an article to low-carb diets. For our family, diet is a way of life.
Our daughter, Alexandra, was diagnosed with diabetes four and a half years ago. At first, while knowing nothing about the illness and the relations between carbohydrate and insulin, we followed traditional medical recommendations. However, we soon realized that it doesn't work for her.
Today, Alexandra is a happy and well-developed nine-year-old who knows her carbohydrate chart well and how much insulin she needs. Her insulin intake went down, as did her lipids and weight. Moreover, by taking Cranberry extract pill once a day, urinary track infections, which she suffered constantly from, became a thing of the past.
We hope that more medical professionals would be aware and open-minded in regard to the tremendous impact low-carbohydrate diets and nutrition supplements might have on their diabetes patients.
East Brunswick, New Jersey
I'm responding to the low-carb article in your February edition which I enjoyed very much.
First of all, thank you very much for calling it a low-carb diet rather than a high-protein diet. I think that throws a lot people off. Your article was one of the few I read in the diabetes/health publications that give a more positive spin to the carbohydrate-restricted diet. I want everyone to know that I've had a great deal of success on this kind of plan.
I've been a type 2 for 10 years, and I had to go on insulin after about two years because I wasn't able to keep my blood sugar under control through oral medication. I think now that was because I was trying to eat too many carbs. The dietitian whom I was seeing recommended that I follow the USDA food pyramid. So for almost 10 years I strugggled with the food pyramid, and it seemed like I started gaining weight, then I needed more insulin, and the fatter I got the more insulin I needed. The end result was I ended up looking like a pyramid at about 215 pounds.
Finally, in 1998, around Thanksgiving, my husband and I decided to give the restricted carbohydrate diets a try. We gave up all the white foods-no rice, no pasta, no bread, no sugar. Believe it or not, within 4 or 5 months, I had lost about 50 lbs. I wasn't low on energy. My husband had lost his enormous front porch. I had gone from wearing a size 22 to size 12. Since we've lost the weight we've added a few more carbohydrates into the diet but we really watch what we eat as far as the refined flour and sugars. By no means do we feel we are deprived. We have a well-balanced diet, just that we go very light on the carbohydrates. I have a HbA1c of around 5.5, my cholesterol is 152, and HDL, LDL and triglycerides are all within normal ranges. My blood pressure went down to normal from very high readings that I had been experiencing. My kidneys are functioning just fine-I had them tested. I don't eat too much protein; only an adequate amount. I just can't say enough about the carbohydrate-restricted diets. If anyone would like to try these diets. I think Dr Eades' book is very good. Also, a book I would like to recommend is the Low-Carb Cook book by Fran McCullough. It was not specifically written for diabetics but it does give a lot of cooking tips and recipies for people who want to embark on a low-carbohydrate lifestyle. She gives a lot of food chocies and a lot of cooking tips. I was really happy to get her book to give us a little more latitude in our diet.
Alberqueque, New Mexico
Thank you for the un-biased article on low-carbohydrate diets (February 2000). I am writing this while my annual renewal notice from the American Diabetes Association (ADA) sits in front of me. The ADA preaches that one diet is the solution for all diabetics - that a newly-diagnosed type 2 should follow the same diet as a type 1 taking four shots per day. I bought into that when I was first diagnosed five years ago. My doctor started me on drugs to try to control my sugar and, of course, the ADA "cure-all," low-fat diet. That wasn't working too well for me. After a while, I told him that since I was only 47 years old, I didn't want to use up all my treatment options at such a young age. So, two years ago, he started me on a low-carb diet (Dr. Atkins). It has made all the difference. Today, I have lost all my extra weight, my HDL's have skyrocketed, my triglycerides are below 40, my blood pressure is where it should be and rarely do my blood sugars go above 100.
Two things happened during that time that made it easy to follow the diet. First, there was the British study that confirmed that absolute control of blood sugars was essential for the delay and, perhaps, avoidance of diabetic complications. Second, was watching a good friend with type 2 diabetes suffer a heart attack, loose three toes and, just recently, lose kidney function, all the while on the standard ADA treatment (and that other ADA, the American Dietetic Association).
I have two sisters that are type 2s and three other siblings that will be if they continue to follow the standard food pyramid. And I can only watch helplessly. Until both of the ADA's come to the understanding that, genetically, some of us are different, diabetes will continue to increase rapidly.
I am pretty angry right now so yes, I will let my ADA membership expire. They have done anything for me. Maybe in a few years I will give them another chance.
Diabetes Health is the best source of information on diabetes that I know of. I am writing about the article in the February issue on low-carbohydrate diets. The article says that Joy Pape, RN, CDE, who has investigated various versions of the low-carbohydrate diet, is "disturbed at the alck of research." One of the books cited in the article is Protein Power by Drs. Michael and Mary Dan Eades. If they are to be believed, there is plenty of reserach to back up their position. The establishment has simply failed to put the pieces together.
When I first read of low-carbohydrate diets (in the pages of Diabetes Health), I must admit that I was skeptical. But having read Dr. Bernstein's Diabetes Solution and Protein Power, I was convinced. I have type 2 diabetes, diagnosed in November 1996, and the doctors I have seen tell me I don't need medication. Before reading these books, I thought I had good control. One day (before I switched to a low-carbohydrate diet), I tested my blood an hour after a breakfast of cereal, toast and milk, and got a glucose reading of 210. I knew then that I had to make a change. I have been on a low-carbohydrate diet for about a year, and am feeling fine, thank you. Today, two hours after lunch (a very satisfying tuna salad), I got a reading of 94.
I'm really tired of all the articles in diabetes publications on losing weight because I have never been overweight. In fact, all my life (I am now 69), I have been on the embarrassingly thin side. The article cites Marion Franz, MS, RD, CDE, one of the crticis of low-carbohydrate diets, who said that insulin is not to blame for insulin resistance. "It's the other way around," says Franz. "Obesity makes you insulin-resistant." I would like to ask Ms. Franz on what basis she says that. Also I would like to ask her why I, who have never been obese, have diabetes.
Needless to say, it's extremely distressing when different experts tell you different things.
San Francisco, California
Although it is true that obesity does appear to cause insulin resistance, there are other causes as well. As you pointed out, you are thin. It is reported that approximately 50% of men and 70% of women who develop type 2 diabetes are obese. However, as you can see there are also a large number of people who develop type 2 diabetes who are not obese. Other risk factors for developing insulin resistance and/or type 2 diabetes are genetics, the aging process, sedentary lifestyle, and ethnic background. There may also be other risk factors not yet identified. So you can see, you are not alone in being thin and having type 2 diabetes.
You may have also read or heard about a large study related to type 2 diabetes that was just completed in Great Britain. The study was called the United Kingdom Prospective Diabetes Study (UKPDS). As a result of this long-term study, medicine learned much about the natural progression of type 2 diabetes. It has become clear, as a result of this study, that type 2 diabetes is a progressive disease. This is not the result of the individual doing anything wrong, rather it appears that the longer individuals have diabetes the problem shifts from insulin resistance to insulin deficiency. This means that eventually the pancreas can not keep on producing the insulin that is needed. What this also means is that many individuals, initially, may be able to control their blood glucose levels well just by being careful of what they eat. Eventually, however, many of these individuals, through no fault of their own, will require oral medications to control blood glucose levels and eventually a large number will require insulin. However, all the medications will work better if individuals continue to be careful of what they eat.
Obviously the low-carbohydrate diets work. However, it is important to also remember that many carbohydrate foods are important for good health, for example, fruits, vegetables and grains. It would seem that people with diabetes should also have "the right" to be able to eat a healthful diet, just as the general public has this right. However, each individual with diabetes makes their own decisions on what they are willing to do to manage their diabetes.
Good luck to you. I hope this information will answer your question.
Marion J. Franz, MS, RD, CDE
I read your article and I certainly could relate. My daughter turned 12 yesterday and was diagnosed with type 1 diabetes right after Christmas 1999. As a result I learned a lot about type 1 and how to manage the disease very quickly. I am very grateful for the terrific education and help that I received I continue to receive. As I learned about the complications I now try to help my mom manage her type II diabetes which I don't understand nearly as much as she is on medication and not insulin. I finally got my mom to go to a specialist and she is now testing 2 times a day. However she is still refusing to go for education. I am still asking myself the question, How hard do I push? What else can I do. The fear of complications are very real. She already has neuropathy in her calves and feet. I know there's help out there but how do I make her get it. I did give her a copy of your magazine to read but she did not mention that she read your article. I'll show it to her again. Thanks.
I am an RN/CDE working as a nurse educator in a hospital out-patient setting. Diabetes Health is the only publication I read cover to cover.
I recently discovered Diabetes Health and find it uplifting and bold. I am the mother of a 4-year-old child with diabetes and I use herbs and vitamins in our fight against the unknown future of diabetes. I saw a past article on Pro-Beta with a reference to a mom who tried it with her 5 year old. It was so affirming to see another parent trying something nutritional. Diabetes is a wasting disease and I get so discouraged with the lack of good nutrition information, especially for kids. There is so much more than counting carbs (5 Nilla Wafers is one exchange, but offers no nutrients to speak of!). I'm not sure if the herbs and vitamins I put in his smoothie are doing anything in that little body but I feel better, more empowered, and pro-active when I do it and I won't wait for a scientific study to confirm it! We've switched to soy milk, try to eat organic, snack on B-vitamin rich nuts, eat blueberries and stay away from hydrogenated fats. Little things add up. Even cinnamon is said to have a positive affect on blood sugars so we sprinkle it on applesauce! If standing on my head while he ate helped, I'd do that too! In summary, I found other diabetic mags redundant and depressing and find yours full of hope. Thank you! I'd love to hear from other moms if possible (Ludlumly@aol). Is there any way to contact the mother of the 5 year old on ProBeta? Thank you again.
A Guerilla mom
Pancreas Tonic Worked for My Son
I want to mention that after reading the January story on Pancreas Tonic ("Pancreas Tonic Looks for Credibility From Mainstream Diabetes Community," p. 21), my son decided he wanted to try it. Well, that has been the other best thing to happen to him. He started taking Pancreas Tonic on January 15. His previous HbA1c reading, in November 1999, was 7.2%. Well, he went back to his endocrinologist on February 18 and his reading was 5.2%.
In addition, he has only been over 130 mg/dl three times since January 15 and only one of those times was he over 200 mg/dl. The only reason he was over 200 was because he went so low that I overtreated his low.
The only problem we have is that his blood sugar readings have been below 60 mg/dl on a very regular basis. He has actually started to reduce his insulin intake. We are very excited about it. My son is still in honeymoon, though, so we don't know if he will have similar success when his pancreas no longer makes any insulin. However, we do know that this is due to the Pancreas Tonic, not the honeymoon phase, because prior to taking the formula, his readings were up and down and frequently well above 200 mg/dl, and even as high as 300.
You can count us as happy customers!!
St Louis, Missouri