A Vote for Reality

I felt there was something not quite right about the cover picture of the hand on the April 2009 issue. Then it finally hit me: That is one smooth index finger. After 31 years of diabetes, my fingers look nothing like that. Scars, scabs, fresh pricks—that is what a diabetic's finger looks like. I challenge you to find someone who has had diabetes for 40 years, who checks his or her blood sugar at least four times a day, and to put that finger on your cover. It might be shocking for some, but for me it proves that I have diabetes and that I am going to do everything possible to keep my disease under control.
Jean Ashmore, Greenville, S.C.

Cleaning the Injection Site

I was surprised to observe in "Insulin Injections: A Step-by-Step Guide" [April '09, p. 40] that there was no mention, especially in Step 6, of preparing the injection site by cleansing with an alcohol swab or at least soap and water. I was also taught to cleanse the bottle top with an alcohol swab.
Bob Lynn, Louisville, Ky.

The "Insulin Injections" guide omitted a couple of steps: wiping the top of the insulin bottle with an alcohol swab prior to insertion of the needle, and wiping the injection site with alcohol before injection. I have some nursing experience, and nowadays with antibiotic-resistant bacteria like MRSA (methicillin-resistant Staphylococcus aureus), an extremely nasty type of staph infection that can be fatal, I stress the importance of preventing infection.

Also, the guide did not mention rolling the insulin bottle between your hands if you are using an insulin that is a suspension and not clear.
Faith Robin Buchin, Tucson, Ariz.

The Editors respond: When injecting insulin, your hands and your injection site should be clean and dry, but no alcohol is needed. Alcohol is an antiseptic; it does not sterilize the skin. However, if you choose to use alcohol on the injection site, it's best to wait until the alcohol has dried before injection, to avoid stinging.
The top of the insulin vial does not need to be wiped. It is true, though, that before using any insulin in a suspension (NPH, premixed insulins), you should gently roll the vial or pen between the palms of your hands to resuspend the insulin.

Looking for Pump Gear

The "Pumped Up" article in the March issue [p. 43] mentions special clothing and pajamas to hold an insulin pump for children with diabetes. Where can those be found?
Judy Russo, Cross Lanes, W.Va.

The Editors respond: While we haven't tested them ourselves, such products are available from a number of small companies, sometimes founded by parents of kids with diabetes. Some examples: Angel Bear Pump Stuff, Pump Wear, Kangaroo Pump Pockets, and Skidaddle Bags, all of which are searchable on the Web. In addition, some people find it easier to sew their own pouches into their clothing, or to hire a tailor to do so. Readers, please feel free to send in information about pump accessories that have worked for you so that we can share it with others.

Good Customer Service

I'm writing in response to Meshell Lavina's letter "Before Choosing a Pump" [Apr. '09, p. 12], in which she stresses considering customer service when choosing an insulin pump. I would recommend that people experiencing these problems with service switch to a different pump supplier. I'll share my experience, which is the opposite of Ms. Lavina's.

At noon one day I was away from home, and without my cell phone, when I had a minor problem with my pump. I got home at 3:30 and promptly called Medtronic. Within two minutes I had a technician on the phone. He had me perform two tests on the meter and pump. His reply: "You have a computer defect in the pump." He then verified the model and serial number, and my name and address.

The technician said, "We will overnight a replacement pump to you with a return envelope for the defective one." The next morning, at about 10 o'clock, I had my replacement pump in hand, along with instructions for returning the defective one, at no charge. This is what I call service, and I greatly appreciate the opportunity to share this experience.
Denzil D. Kastner, Leesburg, Fla.

Butter or Margarine?

Your article "Virtue or Vice" [March '09, p. 47] piqued my interest by mentioning the controversies over using butter versus margarine, but you never did answer the question: Which is better?
Barbara Ashburn, Via the Internet

Associate Editor Tracey Neithercott responds: Margarine wins, says Catherine Champagne, PhD, RD, a professor of nutrition and chronic diseases and chief of nutritional epidemiology at the Pennington Biomedical Research Center at Louisiana State University. That's because butter is loaded with saturated fat. Your best bet: a light margarine that has zero grams of trans fat and is low in saturated fat.

Allergic to Fish

In the February issue, you had a letter about increasing fish intake to get more omega-3 fatty acids [p. 13]. My problem is that I am allergic to all fish except for tuna. That makes it very hard to eat the omega-3s that you say a person needs. Do you have any other suggestions?
Bonnie L. Edwards, Saginaw, Mich.

The Editors respond: You can get omega-3 from flaxseed oil and flax meal, walnuts and walnut oil, pecans, olive oil, and canola oil. You can also eat omega-3-enriched foods, including omega-3-enriched eggs or hemp-fortified foods. In our February article "The A-to-Z of Omega-3," we provided two non-fish recipes: Flaxseed and Raisin Muffins, and Curried Brown Rice Pilaf With Walnuts. If you can't get enough omega-3 from your diet, consider taking a supplement, such as omega-3-enriched algae. Even people who are allergic to fish may be able to take fish oil pills to increase their intake of omega-3, because they don't contain the proteins that cause an allergic reaction.

A Sweet Alternative

I am responding to Carolyn Ruck's letter mentioning her intolerance of Splenda [Feb. '09, p. 16]. I feel you missed the mark by advising her mainly to try experimenting with the level of pure sugar she could have. You should have mentioned a new sweetener with the brand name Truvia. This is not an artificial sweetener; it's made from the stevia plant. Stevia used to be available only in health food stores. Truvia contains a natural sweetener found in fruits like grapes and pears. This product may be better for her and provide the sweetness she is seeking in recipes.
Rebecca Evans, Fremont, Ind.

Sue Robbins, RD, CDE, responds: You're right that Truvia can be used for cooking and baking. Truvia is made from the leaves of the stevia plant, which has been used by indigenous people in Paraguay and Brazil for centuries. South Americans and Japanese manufacturers have used stevia since the early 1970s, without reports of adverse health effects. Truvia also contains the sugar alcohol erythritol. While sugar alcohols can cause stomach problems, erythritol is unlikely to do so because only a little of it is absorbed by the body. Truvia should be an acceptable sweetener if used in moderation; of course, people with diabetes should monitor its effect on their blood glucose levels. For more information about Truvia and other alternative sweeteners, read this month's Food for Thought column, "How Sweet It Is," on page 29.

How Low Is Too Low?

I understand that an A1C higher than 7.0 exceeds the recommended goal for people with diabetes and means frequent hyperglycemia (high blood glucose). Is there an A1C number that people shouldn’t go below, due to risk of hypoglycemia?
Leon Kramer, Goose Creek, S.C.

American Diabetes Association Vice President for Clinical Affairs Sue Kirkman, MD, responds: The "normal" range—the A1C number for people who don't have diabetes—is about 4.8 to 6.0. Someone with type 2 could safely be in that range if he or she isn't on medication that can cause hypoglycemia (for example, someone could lose weight and be on metformin and have an A1C of 5.4 or so, and be fine). On the other hand, a type 1 on insulin or a type 2 on insulin or a sulfonylurea might be having a lot of hypoglycemia with an A1C of 6.8. So it's difficult to give an across-the-board minimum.

However, if you are getting a lot of blood glucose readings below 70, or even just one or two severe hypoglycemic episodes in which you are passing out or experiencing other serious symptoms, then your control may be too tight. An optimal blood glucose for you may be different from an optimal blood glucose for someone else, and you and your doctor need to look at your blood glucose monitoring in addition to your A1C to determine the best treatment plan.

Limit Your Carbs

I strongly agree with the letter by Terry Kuhn [Feb. '09, p. 16] about achieving good blood glucose control on a low-carbohydrate diet. In 1987, I was diagnosed with type 2 diabetes following heart bypass surgery. Twelve years ago I started a lower-carbohydrate diet. Within nine months my doctor twice reduced the amount of diabetes medicine that I was taking. My dosage became one quarter the amount that I had taken originally. My A1C also decreased significantly. My diet enables me to maintain my weight, and it works for me.
Ronald Goodman, Livermore, Calif.