Ask the Expert

| Nov 1, 2001

One of Diabetes Health's most popular sections is its "Question & Answer" column. Our readers ask questions that cannot always be answered in a 10-minute office visit, and we pose these questions to our arsenal of diabetes professionals who offer their expertise.

We recently asked our readers, "If you could ask a diabetes expert any question, what would it be?" We received many questions and we asked the people who know best. What follows are the questions you submitted with the answers we tracked down for you. Enjoy!

 

Does Pizza Raise Your BGs?

Why does pizza raise your blood sugar and keep it up?

Barbara Mahaney
Dayton, Ohio

The following was originally published in the May 1993 issue of Diabetes Health ("Pizza Causes High Blood Sugar," p. 4).

Doctors at Yale have discovered that pizza causes unusually high blood-glucose levels over a sustained period of time in people with well-controlled insulin-dependent diabetes.

The study, which was reported in the April 1993 issue of Diabetes Care, consisted of six men and two women who were given two meals on consecutive nights: one was a control meal consisting of high-glycemic-index foods, and the other was a pizza. Both meals contained similar macronutrient composition and caloric content.

The subjects received their usual pre-meal injection of insulin and their blood-glucose and insulin levels were then measured before and for 13 hours after the meals.

At first, the blood-glucose levels measured after the two meals were similar. After four hours, however, the glucose levels derived from the pizza continued to rise and they remained significantly elevated nine hours after ingestion. The free-insulin levels did not differ appreciably between the pizza meal and the control.

This data suggest that pizza has certain properties that exaggerate and sustain after-meal blood sugar, and such reactions cannot be dismissed as overeating. Although the cause is not known, the discovery is important because the induced high blood sugar occur long after the meal. Simply increasing the pre-meal dose of insulin may not be enough to compensate for it.

Are Type 1s With Low A1cs in the Same Category as Non-Diabetics When it Comes to Getting Complications?

If somebody with type 1 diabetes continually has A1c results in the normal (4.5% to 6.5%) range, is it true that he or she is not likely to have complications?

Charlie Phelps
Maple Plain, Minnesota

This statement is absolutely correct, as proven by the Diabetes Complications Clinical Trial. In this very reliable study conducted by the National Institutes of Health (NIH), it was determined that people with diabetes with A1c levels of less than 7% have the same chance of developing small vessel disease (hardening of the small arteries in the retina, kidneys and nerves), than with people who do not have diabetes.

Greg Arsenis, MD
VA Medical Center
Bay Pines, Florida

 

What is Frozen Shoulder and Why Do People with Diabetes Get It?

I am a 53 year old type 1 diagnosed in 1985 — a later bloomer! My A1c is always between 6.2 to 6.8%. My question is about Adhesive Capsulitus (Frozen Shoulder). I've got it now for the fourth time; it affects alternating shoulders. Having always been in near perfect control since 1985, why does this come back? Better yet, why do I have it to begin with? I have discussed this with my doctors, endocrinologist and therapist and they say people with diabetes are more prone to get it.

Tom Gorecki
Maple Grove, Minnesota

This article ("Frozen Shoulder—11% of People with Diabetes Get It. Readers Want Answers") originally appeared in the March 1996 issue of Diabetes Health. It is an interview with Richard K. Bernstein, MD, a Diabetes Interview board member and diabetes specialist from Mamaroneck, New York. Here we present a summary of that article.

Diabetes Health: Can you explain exactly what Frozen Shoulder is?

Bernstein: Frozen Shoulder—also called shoulder capsulitis—is a common complication of poorly controlled diabetes. Although this condition affects both shoulders, it is usually much more severe on the dominant side.

Diabetes Health: What are some of the characteristics of Frozen Shoulder?

Bernstein: A characteristic is the presence of tender trigger points. These are little spots that a physical therapist or physician can locate in the vicinity of the shoulder that are both tender and slightly hardened as if they were knots in the muscle. Commonly, we find one spot in the trapezius muscle, which extends from the shoulder to the neck; another spot is often located on the deltoid muscle, which is on the outside of the shoulder; and another spot is located in the anterior joint capsule, which is at the front of the shoulder joint.

Diabetes Health: You say that the condition can be found on both sides of the body. How do you determine the severity and exact location of the condition?

Bernstein: The following test, which I perform on all my new patients, will readily disclose this condition in its earliest stages—before the patient suffers any discomfort.

I ask patients to put their hands behind their backs and reach up from below as far as they can with their thumbs pointed upward. This way, I can see how far the thumb can extend up the back. I mark that point and then have patients do the same thing with the opposite hand. If Frozen Shoulder is present, the arm affected will not reach as high as the other arm. Initially, the distance between the two points may be less than an inch, but as the condition progresses, it can be as great as 12 inches.

Diabetes Health: What kind of treatment do you recommend for this?

Bernstein: I use three approaches to treat Frozen Shoulder and find that using all three simultaneously has the most rapid effect.

  1. Trigger point massage: This can be done by a physical therapist, physician or family member and is quite painful if done properly. The trigger points should be massaged until they soften up.
  2. Variable frequency interferential electrical stimulation: This involves placement of special electrodes on the shoulder for the purpose of introducing low intensity electric currents. Most physical therapists, physiatrists and rehabilitation departments of hospitals have the appropriate equipment.
  3. Exercises: Can loosen up the adhesions in the shoulder. The exercise I like best involves lying prone upon a bench while lifting dumbbells. The dumbbells are raised outwardly to the sides for one set, forward toward the head for another set, and toward the rear or legs for the third set. As flexibility improves, the weights of the dumbbells and the number of repetitions are increased.

Diabetes Health: How often should the treatment be given?

Bernstein: Ideally, the above treatments should be rendered three times per week. Most people do not have this kind of time available, so I would suggest a minimum of one set of treatments per week. This combination of therapy is quite effective for Frozen Shoulder.

Diabetes Health: One of our readers said that his shoulder was almost back to normal, but admitted that it would never be 100 percent well again. Is this correct?

Bernstein: I do not know of any therapy that will prevent the shoulder from freezing again if blood sugars continue to be elevated. Therefore, near normalization of blood sugar is essential if a permanent cure is to be achieved.

Diabetes Health: One reader's doctor said that as a last resort, surgery could be done on the nerves in the shoulder.

Bernstein: Frozen Shoulder is probably caused by glycosylation of protein in the fibers of the tendons that attach muscles to the shoulder. It is not a disease of the nerves. I do not recommend surgery for treatment.

 

How Do I Know if My Husband Really Has Diabetes?

I was taught that anyone with a blood glucose level of over 120 mg/dl was a person with diabetes. My husband has been running in the 150s to 200 mg/dl range two to three hours after a meal. I say he has diabetes. Our doctor—who has not done an A1c test—says no. My husband has all the symptoms and wears his weight in his middle. He also urinates constantly and is always thirsty.

Who's right?

Dore Zwingman
Oakhurst, California

There is more than one way to diagnose diabetes.

The American Diabetes Association (ADA) uses the fasting glucose. A fasting glucose over 126 mg/dl on two occasions is diagnostic of diabetes. The World Health Organization (WHO) prefers the oral-glucose tolerance test. If the two-hour glucose value after a glucose load is over 200 mg/dl, then the person has diabetes. This test will diagnose more people with diabetes than the fasting glucose, but it is less practical to perform.

In addition, a random glucose (any time of day) over 200 mg/dl with classic symptoms of diabetes (excessive thirst, excessive urination, excessive hunger) is diagnostic of diabetes.

The A1c is not a diagnostic test. Rather, it is used to monitor the progress of the patient, and helps the physician in adjusting the therapy.

Your husband has glucose values in the 200s, and complains of excessive thirst and urination. I believe he has diabetes and should be managed accordingly.

Pierre S. Najm, MD
Department of Endocrinology, Diabetes & Metabolism
St. George's Hospital
Beirut, Lebanon
American Board Certified

 

Is it Safe to Take Glucophage Closer to My Meal Time?

I am presently taking 500 mg of Glucophage—three times daily—before each meal. When I take the pill 10 to 15 minutes prior to eating, I often have a bout of diarrhea soon after eating. Is this okay, and will the Glucophage work properly if I take it three to five minutes prior to eating? People have told me to do that, but that is different than what the doctor told me.

Diane Mintz
Corner Brook
Newfoundland, Canada

The diarrhea associated with Glucophage is dependent on three factors:

  1. the dose
  2. the timing with respect to meals
  3. the amount of time you have been taking the medication.

As you would suspect, the higher the dose the more likely the diarrhea, so more occurs with the 1000-mg pill than with 850 mgs, and more with 850 mgs than with 500 mgs. If you take the pill three to five minutes before the meal, you are very likely to have the diarrhea as well.

I tell my patients to "put the pill in [their] mashed potatoes," or literally, take it in the middle of the meal, not before and not after. Absorption of the medication does not change appreciably when doing this, and the diarrhea is much improved.

For those just starting the medication, I recommend one 500-mg pill at dinner for one week, then one at breakfast and dinner for one week, and then finally one with each meal. For those who still have diarrhea during the start-up period, I also recommend using Imodium. Doing this, I have only had three patients in nine years unable to take the 1500-mg per day dose of Glucophage.

Todd Burstain, MD
Clinical Assistant Professor of Medicine
University of Iowa
Iowa City, Iowa

 

What Can I Do About Neuropathy Pain in My Feet?

I have been suffering from type 2 diabetes the last 25 years. I am 73 years old. I take insulin injections twice per day—30 minutes before meals. My blood-sugar level at fasting remains around 105 mg/dl. For the last 10 months, however, I have been getting burning sensation in both feet. I have been recommended to take two capsules of gabapentin every day—one in morning and the other at bedtime. I got a colour doppler test done, which shows reduced blood flow due to asclerotic changes. Please advise if you have any other suggestions. My problem is reduced with gabapentin, but only slightly. Also, I feel sleepy during the day.

Tulsidas Sanghavi
Internet

 

Although your arterial testing shows a decrease in circulation, your symptoms sound more like diabetic peripheral neuropathy (DPN), one of the most common complications of diabetes. Without going into the details of neuropathy, I will address your two concerns: tiredness and lack of symptom relief.

Gabapentin, often dispensed as the brand name drug Neurontin, is marketed for the treatment of seizures. The drug, however, works very well for the treatment of DPN. One of the common side effects of gabapentin is drowsiness. You don't mention what dosage you were given. I always start my patients on low doses and build up slowly. Most of the time people can tolerate lower doses and slow increases. On the rare occasion when a patient feels too tired, I try a different treatment plan.

You may need higher doses to get relief of your symptoms. Although I start patients off on doses as low as 100 mg once a day, I may need to slowly increase to as much as 900 mg three or four times a day. That is 2700 to 3600 mg a day—much more than you are taking now.

All patients with DPN should be on tight glucose control. Alternative treatments include capsaicin cream, anti-depressant medications such as Elavil (amitriptyline), electrical stimulation, alpha lipoic acid, support stockings, non-steroidal anti-inflammatory medications (NSAIDs) and narcotic pain relievers.

Neil Scheffler, DPM, FACFAS
Podiatrist in private practice
Baltimore, Maryland
Immediate past-President, Health Care & Education
American Diabetes Association, Mid-Atlantic Region

 

Should You Refrigerate Insulin Cartridges After They Are Placed in an Insulin Pen?

I've read that it is not necessary to refrigerate insulin cartridges once placed in an insulin pen. Why is that different than insulin in vials?

David Craycraft
Laytonsville, Maryland

It is not different. There is no need to refrigerate insulin vials after you open them. Both vials and cartridges are stable at room temperature for a month. However, you should avoid extremes of temperature, such as freezing and temperature above 100 degrees (like in the glove compartment of a car during the summer).

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

 

Does Type 2 Diabetes Usually Progress to Insulin-Dependent Diabetes?

Is it your experience that type 2 diabetes can be stabilized with reasonably good management and remain stable for a lifetime? Or is the logical prognosis that type 2 eventually progresses into insulin-dependent type 1, with all the concomitant maladies of type 1 combined with aging complications (necrosis, amputations, blindness, etc.)?

Lloyd Rain
Eugene, Oregon

There are no definitive studies that answer your important question. However, what you describe precedes all the current advances in medication and monitoring that provide much better control and that may protect the insulin-producing beta cell.

There are good reasons to be hopeful that the progression of type 2 diabetes can be changed for the better:

First, by identifying people at risk for diabetes. The Diabetes Prevention Program has now proven that modest diet and exercise or the use of Glucophage can postpone and perhaps prevent diabetes (see "Proof is in the Numbers," Diabetes Health, October 2001, page 15). So, timing our interventions much earlier in the process of diabetes may be key.

Second, multiple authors—myself included—have reported years of stable A1c in people with type 2 diabetes once they are brought under optimal control with lifestyle changes and by taking Glucophage, Actos or Avandia. So getting perfect control may preserve beta-cell function, perhaps by removing a toxic effect of high BGs.

Third, oral agents for type 2 diabetes historically involved chronic stimulation of beta cell insulin production. Newer agents don't. Many of us believe that this will help avoid beta cell loss through "overuse."

Finally, it is clear that tight control prevents complications and that the newer treatment strategies make lifestyle much more normal. The prevention of "inevitable deterioration" has already occurred for practical purposes. I bet the future will continue to be more optimistic.

Daniel Einhorn, MD, FACP, FACE
Medical Director
Scripps Whittier Diabetes Program
Diabetes and Endocrine Associates
La Jolla, California

 

How Can I Tell if Insulin Has Gone Bad?

I am a public health educator and was recently posed a question about insulin "going bad." Can you tell by looking if insulin has become unusable? Are there certain observable characteristics one should look for? What are recommendations as far as what temperatures are safe for it? Any assistance you can provide would be most appreciative.

Betty King
Public Health Educator
Boise, Idaho

Editor's note: We asked Eli Lilly to respond to this reader's question:

The following general information applies specifically to insulin products manufactured by Eli Lilly and Company, including Humulin (human insulin of rDNA origin), Iletin (insulin of animal origin) and Humalog (insulin lispro of rDNA origin).

The following statements apply across all insulin products:

  • Insulin products should not be used after the expiration date stamped on the vial label.
  • Insulin that has been frozen should not be used. Freezing may alter the chemical and physical characteristics of the product.
  • Insulin should not be exposed to direct heat or light.
  • Insulin should be inspected prior to each dose.
  • Rapid-acting and Regular short-acting insulins are clear and colorless liquids with a water-like appearance and consistency. They should not be used if they appear cloudy, thickened or slightly colored, or if solid particles are present.
  • Insulin suspensions and pre-mixed insulins must be carefully rotated multiple times before each injection to uniformly mix the contents. Insulin suspensions and mixtures should appear uniformly cloudy or milky after mixing.

As with all insulin products, it is best to follow the specific storage guidelines for each insulin formulation. Guidelines for vials, pens and cartridges may differ. These guidelines can be found in the product package insert.

If you have further questions about an Eli Lilly insulin product, please contact us at (800) 545-5979.

John H. Holcombe, MD
Medical Advisor
Eli Lilly and Company
Indianapolis, Indiana

 

How Can Stem-Cell Research Benefit People with Diabetes?

I'm a type 1, diagnosed 50 years and five months ago at age 17. I want to know what progress has been made on stem-cell research with respect to diabetes.

Antony W. Merz
Portola Valley, California

Editor's Note: On July 31, for the first time ever, Israeli researchers turned human embryonic stem cells into a mass of islets which, in turn, produced insulin.

The study was conducted by researchers at the Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology and the Rambam Medical Center in Haifa, Israel. Suheir Assady, MD, led the study.

Dr. Assady has been gracious enough to respond to this question for Diabetes Health:

The field of stem-cell research is young, but holds a lot of promise for providing a potentially endless source of replacement tissues for people with diabetes. Although clinical applications are still a number of years away, major breakthroughs have recently been made related to diabetes.

In initial studies, mouse embryonic stem cells (mESC) were used. According to a study published in the February 2000 issue of the journal Diabetes, Bernat Soria and colleagues managed to select insulin-producing cells from a mixed population of differentiated mESC. These cells reversed diabetes when injected into diabetic mice.

More recently, using different techniques and tissue-culture conditions, a group led by Ron McKay managed to enrich the differentiating mESC with a sub-population of cells containing insulin, glucagon and somatostatin-producing cells. These cells are similar to those residing in the islets. Dr. Mckay's study was published in the May 18 issue of Science.

In our recent study that was published in the journal Diabetes (see "From Stems to Islets," Diabetes Health, October 2001, page 15), we utilized human embryonic stem cells as an alternative. We have shown that these versatile cells are capable of producing and secreting insulin following differentiation under various tissue-culture conditions in relatively high numbers (about one to three percent of cells). As well, the cells express different genes known to be important in the developing pancreas. So we have set the basis for further experiments that aim to eventually use these products to potentially treat diabetes, as well as to gain insight into the normal development of the pancreas.

Interestingly, several groups have managed to isolate and culture special cells from the adult pancreas that are thought to reflect adult stem cells. In a recent study, these cells were also shown to ameliorate diabetes in rodents.

Suheir Assady, MD
Nephrologist
Laboratory of Molecular Medicine
The B. Rappaport Faculty of Medicine
Haifa, Israel

 

What Medications Can I Take for Neuropathy of the Feet and Legs?

Are there any new medications (not necessarily oral) for neuropathy pain in the feet and legs?

Gloria Benitez
Anaheim, California

There are new agents in the research arenas that appear to have the ability to help neuropathy pain. Hopefully, their arrival in the clinic is not too far off.

One of the major reasons that people do not experience pain reduction is that the correct diagnosis has not been made. Secondly, the type of pain needs to be defined because there are different pain syndromes that require different forms of treatment.

If the pain is between the first and second toe and there is tenderness in that space, then it is due to Morton's Neuroma, which is best treated by excision.

If the pain is on the inside of the foot, it is due to entrapment of the posterior tibial nerve and can be relieved surgically. Similarly, if the pain is on the top and outside of the foot, then it is likely to be due to peroneal nerve entrapment and that, too, can be treated surgically.

If the pain is in the heel, it is likely a result of bursitis, and requires orthotics and non-steroidal anti-inflammatory drugs. Similarly, if there is pain in the sole of the foot and it is tender, then this may be due to a fasciitis, which responds best to anti-inflammatory drugs.

If the foot is hot and deformed, this may be due to Charcot's Neuroarthropathy and this is best treated with a bisphosphonate.

If the pain is burning superficial pain with increased sensitivity to touch and pressure then this responds best to Clonidine, topical capsaicin and the new generation of anti-epileptic drugs (Topamax, Gabapentin and Lamotrigine). If these fail, then dextromethrophan, as well as calcitonin, may be useful.

If the pain is deep-seated, a trial of IV infusion of insulin is warranted. For lightning-or sharp-stabbing pain, the drug of choice is still Tegretol. If these fail then Tramadol, a weak opioid derivative, may still be of help.

Ultimately, the only secure solution to this condition is the ability to restore normal nerve function.

Aaron Vinik, MD, PhD, FCP, FACP
Diabetes Institute, Eastern Virginia Medical School
Norfolk, Virginia

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