Letters to the Editor
Diabetes Camp-The Best Thing to Happen to My Son
My son attended Camp Sweeney in Gainesville, Texas, for a week at Christmas time and it changed his life.
He came home upbeat and very confident about himself and his diabetes. His endocrinologist happens to be the camp director and he is wonderful. He helped the kids learn and have lots of fun.
My son is the only kid at his junior high of over 800 students who has diabetes. At the camp, however, everyone had diabetes.
Former Rezulin User Switches to Actos-Now off Insulin
I have been on insulin for over two years, taking three shots a day.
When Rezulin was taken off the market, my physician put me on Actos (45 mg per day). After I was on it for two weeks, my blood glucose started dropping dramatically. By the third week, I was officially off insulin.
I can't believe how Actos has worked. I am amazed and thrilled.
I am also watching my diet closely.
Show More Respect for Diabetes Research
I wanted to respond to your editorial in the May issue of Diabetes Health.
First of all, regarding the American Diabetes Association (ADA), you are correct that their mission is broadr than just supporting research. The organization is also very active in educating persons with diabetes and those at risk for developing diabetes about ways to lower their risk of complications.
In addition to research and education, the ADA serves as a major clearinghouse for advocacy efforts for persons with diabetes. They have been very involved in state-by-state efforts to get legislation passed requiring insurance coverage for diabetes supplies and diabetes education. To date, I believe 39 states have passed such bills, in part thanks to organized efforts supported by the ADA.
The ADA has also been a strong voice advocating for new Medicare coverage for diabetes supplies for all those with diabetes (not just those on insulin) and for diabetes education, as well as insulin pumps for type 1 patients who are on Medicare.
The ADA has also organized advocates for increasing NIH funding so that it approaches a more equitable level in terms of numbers of persons affected by the disease, compared to diseases such as AIDS and cancer. The ADA has set a goal to triple its research funding in the next 5 years.
Regarding your statement that there is very little to show for the money that has gone into research-I'm flabbergasted. To focus just on the NIH: the studies on diabetic retinopathy and the effectiveness of laser therapy were funded by the NIH. Perhaps the Lions Club donated some money to these studies, but the papers discussing the results of the studies list 17 NIH contracts that funded the multi-center study. Secondly, how can you say this is "the only helpful discovery"? How about the DCCT, which showed for the first time that all the effort that people with diabetes put into intensive self-management actually pays off? This $140-million study was funded by the NIH. So was the Collaborative Study Group trial that showed for the first time that captopril protected the kidneys from progression of diabetic nephropathy. The Diabetes Prevention Program and the DPT-1, both very important trials looking at prevention of type 1 and type 2 diabetes, are NIH trials. The NIH has just embarked on a very important trial to look at whether intensive glycemic control alters the rate of cardiovascular complications in type 2 diabetes.
These NIH trials are only the tip of the iceberg, in that they are relatively easy to look at and see the benefits in terms of clinical care. There are thousands more studies that are basic science studies that may not impact you today, but will be critical for understanding the disease and its complications better. Only through understanding the causes of a problem can a solution be found. Those of us who live in the developed world no longer expect that women will have a 1 in 20 chance of dying during childbirth, or that more than half of babies born will die before they turn 5. Because we take our health for granted doesn't mean that we "don't see benefit" from years of research that led to clean water, vaccines, antibiotics, surgical procedures etc.
I would challenge you to really look at diabetes care today and how it differs from that of 40 or even 15 years ago, and recognize that research and the dollars that support it are a huge factor in that progress. For children being diagnosed with diabetes today, the future looks even brighter.
M. Sue Kirkman, MD
Diabetes clinician and researcher at Indiana University School of Medicine
President-elect, Heartland Region Board of Directors, ADA
The Rule of 15 Makes No Sense
I would like to comment on Dana Arnold's answer to Ronald Wiegand on treating low blood sugars in the April issue of Diabetes Health.
I have had type 1 diabetes for 59 years. In regards to the "rule of 15," I don't feel it is logical at all. You would not treat a BG of 70 mg/dl the way you would treat a BG of 40. We are not all alike. The best answer, I have found, is in Richard Bernstein's "The Glucograf Method", outlined on page 191. He recommends that each person calibrate him- or herself to find out how much of a blood glucose rise results from each gram of fast carbohydrate.
I weigh 100 pounds and am moderately active. I usually get a rise of 7 mg/dl for one gram of Dextrose. Dr. Bernstein's book suggests an average value for most adults would be around 5 mg/dl for 1 gram of Dextrose. My own experience tells me this value can change, but you only need to be in the right ballpark.
Thus, it follows that 15 grams of carbs would produce a rise of maybe 100 mg/dl, which is too much unless the blood sugar is very low indeed.
Another important point to remember is that although Dextrose and glucose are best for a low, they should be followed by a slower carb that lasts. I've had excellent results by getting just enough Dextrose to bring me up to 100 mg/dl. Then, I add a few grams of slower carbs like crackers. This amount depends on many factors, of course, such as how soon the next meal is, how active I have been, etc.
St. Joseph, Minnestota
Dana Arnold responds:
I applaud the reader for her diligence in caring for her diabetes. For other readers who want technical instruction, you can calibrate your personal blood glucose rise as the reader mentioned. For many persons with diabetes, a general rule of thumb, like the rule of 15, is safe and appropriate.
While I agree that the rule of 15 may overtreat a hypoglycemic episode, it is only meant to be used as a guideline. When a person feels hypoglycemic, I recommend testing, treating with 15 grams of glucose, then retesting in 15 minutes. This way, they will find out if 15 grams of glucose is adequate. Also, I would not recommend treating a blood sugar of 70 mg/dl but rather, I recommend eating a meal or snack containing both carbohydrate and protein.
Using a guide written by John Walsh, PA, CDE. I use the guideline that one gram of glucose raises the blood sugar three, four or five points for weights of 200 pounds, 150 pounds, or 100 pounds. respectively. For example, if people feel hypoglycemic, test their blood sugar and get a reading of 40 mg/dl, they should treat that blood sugar with 15 grams of glucose. This should result in a blood sugar rise of 45 to 75 points or to a blood sugar 85 to 115 mg/dl, which is a desirable level.
Dana Arnold, MS, RD, CDE
Seton Medical Center
Daly City, California
My Success with the Low-carbohydrate Regime
I was diagnosed with type 1 diabetes in 1957 at the age of 6, and started on one insulin injection daily, which was the usual method, because doctors tried to minimize the number of injections per day for children.
Because my doctor had type 1 diabetes and felt that good blood glucose control should be the major aim, my number of injections was increased to two each day until 1984. I increased it to three each day until 1994. Since then, I have been taking four each day.
I started blood glucose self-testing in 1980, and of course before that, I was testing urine. I now test four times each day (using a plasma-calibrated meter) and I also do low-impact exercise two to three times per week. Apart from mild background retinopathy, I do not have other major diabetes complications that interfere with my life.
In 1998, I became aware of a new approach- the low-carbohydrate, low-glycemic index food plan. I also visited a diabetes center in New York that specializes in this. Its director (Dr. Richard Bernstein) has had type 1 diabetes for over 50 years.
Bernstein adopted this food plan many years ago after a lot of experimentation, and he reported that his diabetes control improved significantly. I was also interested in this approach as I had observed over many years that when my carbohydrate intake was less, my blood sugars improved. This further encouraged me to try this very different food plan. I was intrigued by reports of normal HbA1c's in Dr. Bernstein's book, news reports and Internet site.
Prior to this, I did not adopt this approach because the generally accepted and recommended regimen was a high-carbohydrate food plan and there was no support or encouragement to adopt this major change.
By 1998, the low-carbohydrate diet was being discussed a lot in the United States, and there was increasing discussion in the diabetes journals and at conferences.
I experimented a lot and have reduced, since July 1998, the total amount of daily carbohydrates from about 200 grams to approximately 50 grams, which is all of a slowly absorbed type.
Here are some of the results:
- My insulin dose has fallen by over 35 percent and continues to fall.
- My HbA1c hasimproved by 15% to 6.9% (range 6.3-7.4%) and there is much less variation in daily blood glucose.
- Hypoglycemia is much less severe.
- Weight has dropped from 84 kg to 78 kg.
- Retinopathy has stabilized (my ophthalmologist made particular note of this new trend in its progression)
- Blood pressure and lipids remain normal.
- Hunger has decreased (insulin is an appetite stimulant and this regimen has resulted in much less insulin).
Also, there is much more motivation and less frustration and my subjective quality of life has improved significantly. I will be giving a detailed talk and slide presentation to a Japanese Diabetes Education Center on my experiences with this system of blood glucose improvement.
I do not regard this food plan as "radical" or a "fad." It should not be confused with the extreme food plans which are periodically publicized, especially in America.
The significantly reduced insulin dose has been a major contributor to the reduction in hunger. I no longer feel hungry during the day, however, there is some hunger in the evening. As I continue to experiment with the food plan and the type and range of meals, particularly in the evening, I am confident that this problem will also be significantly reduced. I am very excited about continuing to be able to lower my HbA1c further.
Lowering daily carbohydrate intake makes sense on many levels. Why eat so much of a food type that is at the root of blood glucose instability and which needs much more insulin to try to take care of, which in turn creates further problems? There doesn't appear to be any evidence supporting high carbohydrate intake over lower intake in terms of blood glucose control, yet this is what is being generally advocated and promoted. Also, kidney disease seems to be subsequent to high blood glucose, rather than to higher protein intake, according to professionals such as Dr. Bernstein and his expert colleagues.
The major pharmaceutical manufacturer, Bayer, now endorses Dr. Bernstein's approach, and includes information about it with meters it sells in America. It also cites persons with diabetes who use this approach as "living proof of the success of this method".
Smaller amounts of carbohydrate require smaller amounts of insulin and this results in more predictability and less variation in blood glucose levels.
Ron Raab BEC
President, Insulin For Life Incorporated
Member, International Diabetes Federation Insulin Task Force