Letters to the Editor

April 2003

Apr 1, 2003

Piercing Thoughts

I disagree with Denise Richards's suggestion about piercings and diabetes ("Q&A," December 2002, p. 52).

Granting permission to get a nose ring as a reward for improved A1Cs would do more harm than good. Looking back on my teenage years with diabetes, I can't begin to stress how important it was for me to find opportunities to have fun and be in control of my body and what it looks like outside of having diabetes.

These freedoms are precious to me and remind me that enjoying life doesn't always come with a diabetes "filter." For me, piercings are on that list of non-diabetes-related freedoms. Dyeing your hair, piercing your nose, wearing funky clothes ... any of these things are safe, fun, and give youth a sense of freedom—even freedom away from diabetes. Let them have it!

If, as a parent, you find the idea of a piercing too objectionable, give your children the respect of your honest opinion. Keep it separate from diabetes issues. Relating piercings to diabetes goals just makes diabetes more oppressive, and the goal more emotional and difficult to obtain.

Piercings, much like diabetes, require regularly scheduled attention, especially during the healing period. An extremely useful source of information I have used is the Association of Professional Piercers' Web site at www.safepiercing.org. It sets industry standards for piercing procedures and also publishes top-notch information about getting and taking care of piercings.

Jennifer Dickman
Mahopac, New York

We asked Denise Richards to respond to this reader's concern:

You bring up a very good point. There is, of course, no one correct answer for every person. As you point out, what is a motivation for one person may be a deterrent for another.

I have, however, seen this type of reward approach work successfully for many patients. Most diabetes educators are always looking for some opportunity to encourage a patient. Also, many teens find that once diabetes gets into better control, it is easier to maintain the effort to sustain that control. Ideally, the members of the diabetes care team serve as advisers and encouragers to present information and various options to patients and families and let them decide what will be most helpful. Our role is to support our patients in their decisions toward better self-care.

Thank you for sharing your perspective with us!

Denise Richards, MSN, FNP, CDE
Massachusetts General Hospital for Children, Diabetes and Endocrinology Division, Boston, Massachusetts

A "Perfect" Response

A comment by a reader that appeared in the December 2002 issue of Diabetes Health (" ‘Perfect' Comments," Letters to the Editor, p. 11) destroyed my long-held assumption that it is only physicians who criticize medical treatments without reading them. In her letter, she commented that, with a low-carbo regimen, "you are not eating a balanced diet for your overall health." This could not be further from the truth.

Virtually all of my patients, prior to reading one of my books or seeing me for training, were following one version or another of the American Diabetes Association's high-carbohydrate diet. As a result, they suffered not only from the long-term complications caused by elevated blood sugars, but also the discernable results of malnutrition, such as deterioration of their teeth and retracted gums. This was certainly not helped by the urination of water-soluble vitamins that accompanied loss of glucose in their urine. Carbohydrate, to most, was bread, potatoes, desserts, sweetened cereals, skim milk and pasta—all recommended by the ADA. Deliberate consumption of nutritious vegetables was rare.

Our low-carbo diet attempts to emulate what was available to our ancestors before agriculture (with the creation of bread and, later, sweet fruits) introduced dental disease, atherosclerosis and diminished lifespan. In prehistoric times, humanity survived and evolved eating animal sources and whole plants—mostly leaves and stalks.

When I discovered, 33 years ago, that blood sugar could not be controlled with a high-carbo diet, I remembered that during the twentieth century a new vitamin was being discovered every 15 years or so. I, therefore, assumed that vegetables, as we now know, still contained some nutrients that could not be obtained from vitamin pills. I thus added vegetables to my diet and, to this day, negotiate meal plans with my patients that include vegetables as their only source of carbohydrate. At my insistence, most of my patients eat vegetables at all or at least two of their meals. Now, many diabetics who rarely consumed vegetables are learning to enjoy them.

Humans can survive without carbohydrate, but they cannot survive without essential fatty acids and essential amino acids (found in protein foods). The marvelous outcomes for people who follow our diet appear in testimonials by readers of my book "Diabetes Solution" online at www.amazon.com and www.amazon.com.uk. High-carbo diets are not "balanced" and bear little in common with the diets on which humanity evolved.

I have had type 1 diabetes for 57 years and have been on a low-carbohydrate diet for 33 of those years. This diet has reversed many of my prior long-term diabetes complications, including kidney disease, vascular disease and cardiac disease. I practice medicine and write 10 hours daily and enjoy better health than most physicians many years my junior.

Richard K. Bernstein,
Mamaroneck, New York

Clarification Requested on Sugar Alcohols

I am a dietitian/diabetes educator and have a question about a comment that accompanied Heather Kelsheimer's article "The Sweetest Thing" (November 2002, p. 61).

In reference to sugar alcohols, she states, "These types of lower-calorie options include sorbitol, xylitol, lactitol, mannitol and maltitol." The article then goes on to note that "the sugar alcohols are lower in calories than the sugars fructose, sucrose or glucose."

My understanding is that sugar alcohols contain 4 calories per gram, exactly the same number of calories found in fructose, sucrose and glucose. Could you please comment on this?

Wendy Levin, RD, CDE
Etobicoke, Ontario, Canada

We asked Heather Kelsheimer, MS, RD, CDE, to respond.

The position of the American Dietetic Association states, "Polyols (sugar alcohols) can be categorized as sugar replacers because they can replace sugar sweeteners on a one to one basis, offer less energy and offer potential health benefits. All polyols are absorbed slowly and incompletely."

It is because of this process in the intestine, through passive diffusion, that sugar alcohols have about half the impact of normal sucrose. If sugar alcohols were completely absorbed, the direct metabolism would provide the usual 4 kcal/kg. Because incomplete absorption causes indirect metabolism of polyols via fermentative degradation by the intestinal flora, polyols are referred to as reduced-energy or low-energy sweeteners.

Another good reference to answer your question would be the fourth edition of the "Core Curriculum for Diabetes Education."

Heather Kelsheimer, ms, rd, cde
Terre Haute, Indiana

Tired of Being a Pancreas

After 70-plus years with diabetes, I'm tired of being a pancreas. That's what all people with diabetes "in good control" are. We check our blood glucose, adjust insulin dosage, try to eat to match those measurements, and live fairly "normal" lives, waiting for the elusive cure.

I've been waiting since 1930, when insulin was being hailed as the savior of those who were previously doomed with the diagnosis of diabetes mellitus. I waited through birthdays without cake during childhood and without after-class Cokes at the downtown drugstore through high school. I sometimes sneaked a little of that, then went home to "red" urine sugar tests and added insulin at dinnertime. In college, I seldom checked my urine sugars—they were always high. I took amounts of insulin that filled the syringe, past where the gauge stopped.

After graduation, I worked as advertising manager at a department store, where our ads often featured the candy department, which meant that sample boxes were brought to us and eaten. During that time, I had an eye exam, with the ophthalmologist sending me to the hospital to regulate my diabetes because of incipient blood vessel damage in my eyes. I restricted my appetites, took a three-month trip to Europe, stopped in New York City on returning, and went back to work in advertising/publishing. There I met my husband. We moved to California and raised two wonderful, healthy sons.

I've had great support from my family, fine doctors—many of whom were learning about diabetes from me—and blessings from God (I survived breast cancer in 1994).

But, after all those years, I'm still waiting to have one single day without the insulin shots that keep me alive. I'm "too healthy" for today's miracle cures, though I fight blood-glucose levels of 37 to 390 mg/dl with my pump.

Is there any answer for all this?

Kathleen Anstine
Lake San Marcos, California

Correction: In the February 2003 issue, we reported on calculating insulin-to-carbohydrate ratios ("Insulin to Carbohydrate Ratios: How Are They Calcu-lated?" p. 42).

The formula in Method A was inadvertently reversed. The correct Method A and example calculations are as follows. Method A: The 500/450 rule: 500 divided by TDD (for insulin sensitive), or 450 divided by TDD.

TDD is the total daily insulin dose.

For example, if TDD = 60 units:

500/60 = 8.33, or 1 unit insulin for each 8 grams CHO (1:8), or

450/60 = 7.5, or 1 unit insulin for each 7-8 grams CHO (1:7 or 1:8)

The starting ratio would be the physician's choice, based on your clinical history.

We express appreciation to several sharp-eyed readers who notified us of this error.

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