Understanding Kidney Disease

was diagnosed with type 2 diabetes nearly 35 years ago, and for nearly the same length of time, I was an editor and indexer of biomedical texts. Not in all that time have I seen kidney function and kidney disease so clearly explained as in your August article "Keys to Kidney Disease" [Aug. '09, p. 66].

I have one suggestion, which applies to articles on other diseases, too. It would have been helpful to have introduced the term "renal" when referring to the kidneys, and possibly to mention periodic blood testing for creatinine along with urine tests. Many people with diabetes are stumped by medical terms associated with the disease and are sometimes afraid to ask for clarification when talking with health care professionals.
Lillian Rodberg, Allentown, Pa.

Defining the Doughnut Hole

I'm puzzled by the story "Minding the Gap" [May '09, p. 20] regarding the "doughnut hole" in Medicare prescription coverage. According to all the information I have received for 2009, the gap in Medicare's prescription coverage falls between $2,700 and $4,350, not $2,250 and $5,100, as your article says. The figures are very important since my husband is prescribed expensive medications and will soon be in the dreaded doughnut hole.
Sandi Werthe, Laguna Beach, Calif.

The Editors respond: You are right: The figures cited in the study we reported on in "Minding the Gap" are now out of date. According to the Centers for Medicare and Medicaid Services, the gap in coverage for 2009 is between $2,700 and $4,350 in expenses on prescription drugs. More information about the prescription drug benefit is available at www.medicare.gov/pdp-things-to-consider.asp. An AARP calculator that can help you avoid the doughnut hole is at doughnuthole.aarp.org.

Recipes on the Web

I was diagnosed with type 2 diabetes last December, and am already a member of the American Diabetes Association and a subscriber to Diabetes Forecast. I just wanted to say thanks for also posting such a wealth of information online, especially recipes. I often put a cooler in my car and grocery shop on my lunch break, and it's so convenient to just print out a recipe to prepare that same night. It helps keep me on my meal plan.
Karen Krycho, Plano, Texas

More About Margarine

In the Mail Call letter "Butter or Margarine?" [July '09, p. 16], the writer asks which is better, and the response by Associate Editor Tracey Neithercott is: "Your best bet: a light margarine that has zero grams of trans fat and is low in saturated fat."

Unfortunately, there is no margarine on the market that has zero grams of trans fat. Margarine is based on hydrogenated oil, which by its very nature has trans fat in it. Anything less than 0.5 grams per serving can be legally labeled as zero grams. Even if the label says 0 grams, it can contain up to 0.49 grams of trans fat.

The best bet? A product that is a blend of oils containing no hydrogenation, hence no trans fat. One brand commonly available in most supermarkets is Smart Balance. It has no hydrogenation and no trans fat. There are several types, including a blend with butter, so shop carefully.
Jim Andrews, Auburn, Ind.

Sue Robbins, RD, CDE, responds: It's true that tub margarines contain a very minimal amount of trans fat, and it is also true that Smart Balance is one of the few products with zero grams of trans fat. However, Smart Balance contains saturated fat and must be counted in your total saturated fat budget for the day. The American Heart Association recommends that no more than 7 percent of your calories should come from saturated fat. If you eat 1,800 calories a day, for example, you should limit your saturated fat to no more than 14 grams per day. Most tub margarines have no saturated fat and minimal trans fat, so they are OK to use in moderation—no more than three servings per day. Try to limit stick margarine, because it is high in trans fat, and butter, which is high in saturated fat.

Breaking Down the Walls

I was thrilled by the work of Colin Nichols, PhD, at Washington University in St. Louis to uncover the mystery of neonatal diabetes ["The Littlest Patients," June '09, p. 72]. As a cell biologist who has had type 1 diabetes for 40 years, and as someone who teaches endocrinology, I can say that we are rarely released from our laboratories to communicate with the general public. So, I appreciate the challenge that author Andrew Curry faced in explaining the complex malfunction of the beta cell that causes neonatal diabetes. It is often necessary to devise some creative analogies to make understandable the complex process of insulin secretion.

However, I am quite sure that scientists like myself would find it astonishing that any research of humans or animals would involve studying proteins in cell walls. That is because the only organisms that possess cell walls are some types of bacteria, fungi, and plants. No animal cells that compose you and me have cell walls.
Instead, the pancreatic beta cell has a fabulous structure called a cell membrane (or, even more specifically, a plasma membrane) that actually has inserted within it the wonderful sensor proteins described in your article.

Why should we in the community of diabetics and their researchers worry about such a minor distinction? Most common organizations would not. But ADA is an uncommon advocate for people who live with, treat, and research diabetes. Diabetes Forecast asks us in each issue to "be an informed reader." I bring up this small mistake in the spirit of keeping all of us informed. And, for my next act, I will try to eliminate from our vocabulary the reference to measuring "blood sugar," which none of us ever do. Instead, we measure our blood glucose, thanks to the modern usage of specific enzymes on our test strips. 
Nathan L. Collie, PhD, Department of Biological Sciences
Texas Tech University, Lubbock, Texas

Cocoa and Chocolate

I have a question about the interesting letter "More on Chocolate, Please" [June '09, p. 12]. I am 80 years old, and I've had type 2 diabetes for about 15 years. My diet consists mostly of fruits, vegetables, and fish.

Unfortunately, I also have high cholesterol and high blood pressure, which I control with medications and exercise. I don't eat chocolate, but I have a cup of hot milk with a large teaspoon of cocoa and some artificial sweetener in it. I was wondering whether your experts think cocoa is a good replacement for chocolate, since chocolate has more fat and sugar. 
David Kahan, Troy, Mich.

Sue Robbins, RD, CDE, responds: Yes, milk with cocoa and artificial sweetener mixed in is a healthy alternative that can help you get your chocolate fix. However, cocoa isn't a direct substitute for chocolate in all dishes and recipes, because cocoa isn't sweetened and its consistency is different from chocolate's. So if you can't enjoy cocoa—with the addition of an artificial sweetener, of course—as part of a recipe or beverage, remember that it's also OK to eat dark chocolate in small quantities as it fits into your meal plan. Some people favor dark chocolate because of its antioxidant content. About 2¼ tablespoons of cocoa provide the same amount of antioxidants as 1.4 ounces of dark chocolate.

In June's Mail Call, a reader asked about purchasing healthful but less expensive dark chocolate. I have been a diabetic for more than 10 years, and to save money when buying chocolate, I buy my 3.5-ounce dark chocolate candy bars at the dollar store.
Donald E. Hur, DVM, Lakeside, Ore.

Needle Disposal

I was diagnosed with type 2 diabetes 21 years ago. My doctor was very good about teaching me all I needed to know about managing my disease. But I was never told how to dispose of needles safely.

After learning that this was an issue, I talked about it with friends of mine, at least four of whom had never been told about the proper disposal of sharps. One of my friends was simply putting her needles in the garbage! I think Forecast should be aware that this is happening and should tell doctors to instruct their patients.
Eleanor Willey, Monroe, Mass.

The Editors respond: How sharps should be disposed of may be mandated by your state's laws. Legal obligations aside, it's always important to consider others who may come in contact with your used needles and lancets. Some local fire departments have sharps disposal programs. If you're disposing of sharps yourself, enclose them in a solid container, such as an empty liquid laundry detergent container or a plastic milk jug, that can be sealed shut. Simply screw the lid back on and tape it closed. Label the container "Used Sharps" before placing it in the trash. You can also purchase devices for clipping your needles and disposing of them safely.

A Questionable Diet

The research study described in "A Healthier Way to Lose Weight" [July '09, p. 67] tests a diet that I hardly believe people could follow long term. Cutting out red meat, butter, margarine, cream, and commercial candies and pastries for six months, all while a researcher provides sample menus and monitors food preparation and intake, is one thing. Remaining on such a diet for a lifetime is quite an­-other. Unless this aspect is addressed in the research, I would expect the outcome to be similar to that of weight-loss diets: successful in the short term, but ultimately many participants will end up weighing more than before they began.
Marvin Oed, Cockeysville, Md. 

Touched by Reflections

Sheila Fleisher's Reflections article ["A Tribute to a Friend," Aug. '09, p. 76] was very touching. Diabetes is the fastest-growing chronic disease in our country, and people like Sheila raise awareness of the disease when sharing their stories. My husband, who is a surgeon, has type 2 diabetes. He is coping well. He is 70 years old and working full-time.

In my opinion, the love and support you find in relationships can be the best motivators in helping you take care of your health.
Veena Grover, Dana Point, Calif.