Letters to the Editor
Reaction to Type 2 Feature
After reading your article on type 2s and their difficulties with diet ("Winning or Losing?" June 2002, p. 32), it occurred to me that it would have been a good idea to suggest individualized meal planning with a dietitian who is a CDE or is at least knowledgeable about diabetes.
For example, the "typical daily diet" Susan Ouellette described seemed totally unrealistic to me. It appears to supply fewer than 1,000 calories per day and to be lacking in necessary nutrients. Furthermore, it's hard to believe anyone would adhere to this diet for more than one day. Finding a dietitian and/or diabetes educator who will work with her for several sessions to develop a meal plan tailored to her needs (activity level, weight, food preferences, blood-glucose results, etc.) would allow her to have foods she enjoys while gaining better control of her blood-glucose levels.
Judy Cirillo, NP, CDE
Reading about the overweight type 2s in the June article "Winning or Losing?" makes me think 30 percent of Americans must subconsciously be expecting a famine. These people are obviously not exercising between every meal and have the biggest problem in diabetes: psychological hunger.
If type 2s cannot lose weight and have high A1Cs, they may need to consider doing something drastic like selling their motor vehicles, giving up their insatiable thirst for foreign oil and moving to a bicycle/pedestrian-friendly place like Davis, California; Portland, Oregon; or Seaside, Florida. Then they will no longer drive to the fast food joint at the nearest strip mall and will instead learn to prepare fresh food at home. A top-of-the-line bicycle costs less than going around in a cocoon of steel and glass, does not pollute and improves health.
San Jose, California
Taking Exception to Our Clinical Adviser's Comments
This is in response to Scott King's editorial "The Man in the Mirror" (June 2002, p. 10), to which I can definitely relate. I too have had type 1 diabetes for almost 23 years and at times have early morning lows—which are usually due to overestimation of a bedtime "correction dose." I also find it very difficult to eat only 15 grams or 30 grams of carbohydrates (as per the American Diabetes Association recommendations) and then wait 15 to 20 minutes to recheck and treat again if necessary.
I was angered when I read the comments by DI's clinical adviser, Cindy Onufer, RN, MA, CDE. She was correct in stating, "The key is to be a detective and figure out why the low occurred." However, I feel that she, like many others, does not understand how it feels to have a low. It is so easy to say, "Follow the ADA recommendations" if you haven't experienced low blood glucose in the middle of the night. Neither do I like to eat at 3 a.m. and add extra calories that I don't need.
As a diabetes educator, I am very familiar with the ADA recommendations and instruct my patients accordingly. I also let them know that I understand how difficult it is to manage their diabetes and that I too have the same frustrations.
I thank you for sharing some of your experiences and concerns. I always look forward to receiving Diabetes Health and to reading it "from cover to cover."
Joan Walterscheid, RN, CDE
I was concerned about the comments made by Cindy Onufer, RN, MA, CDE, to Scott King in his June 2002 monthly letter ("The Man in the Mirror") suggesting that the 500 calories consumed during a nighttime hypoglycemic reaction were in excess of what was needed.
This comment epitomizes the problems I see with the carbohydrate-counting diet, where blanket statements are made about how much one should eat, based primarily on numbers. Although I recognize that this is done in an attempt to establish general guidelines to assist patients and healthcare professionals, I feel that it is dangerous for the ADA to label general guidelines as "recommendations"—as though our bodies are carbon-copied machines.
A further note: I do not feel that somebody with diabetes who has a blood glucose of 50 should be quibbling over numbers in the middle of the night. Anyone who has experienced the terror, pain and confusion caused by hypoglycemia knows that you put immediate safety first, do your best not to overeat and then pick up the pieces afterward. There is an emotional component to hypoglycemia that may need to override the physical requirements. People with diabetes need to be supported in not berating themselves when they do overeat during hypoglycemia—which is often inevitable.
I feel that the recent trend toward the carb-counting diet promotes some limited thinking about the multileveled, complex elements contributing to blood-glucose levels. It seems that our focus on numbers in this society has filtered into diabetes care, where we are dealing with individual, nonmechanical bodies and emotional beings.
Scott King's reply: Thank you for your excellent letters. The night of my low, I definitely had a bad case of "diabetic werewolf" syndrome. That's where you must eat and eat (and eat) until you feel better. Cindy's advice about treatment is very good, and something to strive for. Unfortunately, as these writers have mentioned, it is not always easy to follow.
Podiatrist Says There Are Other Choices for Neuromas
Aaron Vinik, MD, in his response to a question about neuromas ("Question About Treatment of Neuropathy of Feet and Legs," June 2002, p. 51) states that after conservative treatment with metatarsal bars, wide shoes and interdigital pads, "...if the pain persists... excision becomes the only clear choice."
There are, in fact, other choices.
For years, a standard treatment option of mine was to inject the neuroma with a steroid, using triamcinolone. Two or three injections helped many patients. I still use this as a treatment option.
More recently, I have been using an injection of 4 percent alcohol. A series of three to seven injections has proven highly effective: most of my patients have had resolution of the pain, and it has obviated the need for surgery. This technique, called chemical neurolysis, would be my suggestion for anyone with a painful neuroma who has not responded to orthotics and other conservative care. The neuroma is still there, but the pain is gone.
Certainly, should these injections not work, exploration of the area and excision of the neuroma should be considered.
Neil M. Scheffler, DPM
Baltimore Podiatry Group
Calling All Famous People With Diabetes
Reading the showcase of celebrities with diabetes in the May 2002 issue of Diabetes Health made me want to applaud Michael J. Fox for all his work to raise funds for Parkinson's re-search. It's not easy to put yourself on display.
However, where are the famous people with diabetes?
Mary Tyler Moore works tirelessly to raise funds for diabetes research. Is she the only person with diabetes in Hollywood?
Celebrities with diabetes should use their fame to do some good for their fellow sufferers. If I were famous, I would make a lot of noise about diabetes and about the urgency of finding a cure.
Comments Regarding After-Meal BGs Feature
Thank you for the article "After-Meal BGs: Just How Important Are They?" (April 2002, p. 52), which was a real eye-opener.
I would just like to make the point that while it may indeed be important and valuable to check after-meal BGs, the reluctance to do so by many people with diabetes—especially type 1s, who should test frequently—is often not an issue of "laziness." ["The ADA has made it so that we can be lazy," says Lois Jovanovic, MD, in the article.] I realize she was probably referring to laziness in physicians, but often the implication is made about patients, too. Testing at less than the optimum level can also become an issue of personal finances.
I test between five and eight times per day. However, I was not always this aggressive with my care in my younger years, partly because of financial constraints. (Other factors were pain issues, a frantic college and work lifestyle, lack of expert doctor's care and, yes, even a bit of laziness.)
At 76 cents per strip (Accu-Chek), testing eight times or more daily costs $6 each day, or $180 per month. Perhaps this is not a significant amount to those with higher earnings, but it's a substantial portion of the average working person's budget—not to mention insulin, supplies and medication costs. In my case, I had to meet a $500 deductible on my insurance before having my strips covered at 70 percent. And with more and more employers now continually forcing employees to "share the burden" of rising insurance costs, testing more frequently becomes a further financial problem. While this is a burden I am willing and able to tolerate, not everyone is in the same situation. The point is that we need to continually strive for better insurance coverage and more reasonable costs for BG testing to truly help us take better care of ourselves and live our best lives.
Angi Van Remortel
Clinical adviser's note: Financial concerns, as you so effectively state, are often a barrier to diabetes self-care. One approach to assessing patterns of blood-glucose control both pre-meal and after-meal with a limited test strip supply is to vary days/times of checking, with occasional tests done at all the desired times. While this method may give only occasional after-meal results, the data might be enough to help in planning meals and exercise and evaluating the effectiveness of medication dosages.Click Here To View Or Post Comments