Great Reflections

I have been reading Diabetes Forecast for nearly 30 years, and it is one of the few magazines I read completely every month. I particularly enjoy the Reflections articles and especially liked Sharon S. Epstein's story, "A Taste of Childhood" [June '09, p. 84]. It served as a vivid reminder of what life is like in the "real world" and of the many demands made on people who are managing diabetes.
Eugene Gaeta, PhD, Manasquan, N.J.

A Favorite Recipe

I enjoyed looking at the recipes in the June issue [p. 36]. The exotic dishes sound great.

This may not be exotic, but my wife of 63 years and I have long enjoyed the same breakfast. It consists of Cheerios with fat-free milk and a blend that I prepare in a separate container: oatmeal flakes, dried apricots cut in small pieces, dried raisins, small pieces of walnuts, and ground cinnamon. It's topped off with whatever is in season—usually strawberries or blueberries. Try it!
Carl Weinert, Tucson, Ariz.

Self-Monitoring Success

I'm writing about your article "Checking Your Blood Glucose" [April '09, p. 32]. I hope all diabetics appreciate the miracle of home blood glucose meters. I have always felt that the rollout of the first meters in the 1970s marked the greatest advance in blood glucose control since the discovery of insulin in 1921. Before my husband purchased my first meter for me as a Christmas gift (I think it was in 1975), the only thing I had was urine testing, which in no way offered the kind of blood glucose control that you can achieve with a meter. 

Those first meters required several steps and gave only a range of results, not an exact number. It was easy to make mistakes. Today's meters are head and shoulders above them. I could go on and on about all the wonderful advances I've seen over the years, but home blood glucose testing stands out as one of the very best, if not the best. Appreciate this tool. It's a miracle of modern technology and innovation.
Rita Pemberton, Bristow, Va.

Insulin vs. Sulfonylurea

I was disappointed in Craig Williams's response to "Can I Switch to Insulin?" in Ask the Experts [May '09, p. 17], in which the letter writer asked, "Is it true that there is not an insulin dose low enough for me?"

The letter writer obviously had read about the benefits of insulin over multiple oral medications and wanted to change her therapy. The response quickly said "there would be no benefit to switching to insulin," assuming that any benefits the patient perceived were wrong. Perhaps she was concerned about the theory that sulfonylureas may accelerate beta cell exhaustion. Perhaps she wanted the flexibility of adjusting an insulin dose to handle changes in meals or activity. Perhaps she would have liked the autonomy of titrating her nighttime dose to diminish morning hypoglycemia. If the patient perceives that insulin therapy has benefits, that, in itself, is a benefit.

Physicians often say they cannot get patients to start insulin because of needle phobia. Here you had a patient who wanted to take insulin, and her physician was apparently not even discussing the pros and cons with her, simply telling her "there is not a dose low enough for you." She didn't seem to trust that answer and turned to Ask the Experts—and didn't get an answer. How is that empowering the patient?
Brenda Scruggs, MSN, RN, CDE, Overland Park, Kan.

Craig Williams, PharmD, responds: This is a topic of debate in diabetes care that will lead some experts to "agree to disagree." While there is no question that insulin is a vital hormone, the effects of injected insulin in patients who have insulin resistance (as in type 2 diabetes) are complex. Patients shouldn't be given the impression that insulin is superior to other treatment options without evidence from human clinical trials. To date, no such evidence exists. In fact, research results presented at the American Diabetes Association's 69th Annual Scientific Sessions in June help to refute this. One five-year study of 2,400 participants demonstrated that insulin provides no additional benefit for cardiovascular health when blood glucose control is already managed with medication.

I completely agree that it is always helpful to have patients express a willingness to use insulin as part of their diabetes management program. Insulin is a necessity for patients who are otherwise unable to achieve glycemic control. But in the case of the letter writer, she had already achieved good glycemic control, and my response was to assure her that she was not missing out on any additional benefits just because she was not using injected insulin. In that regard, I agree with her prescribing physician.

Getting Back to Basics

It was nice to see a basic article for diabetes beginners ["Back to Basics," April '09, p. 31]. When I was first diagnosed, I felt that I'd been dropped into the middle of a novel. No one, including medical professionals, taught me the basics. Here are tips for blood glucose testing that have worked for me in the five years since I was diagnosed:

• I use a different finger for each pre-meal test and at bedtime.
• Each month, I switch hands, giving the fingers a break.
• I always inject my Lantus on the right buttock (right for night), and my Humalog on the left.

Having a routine helps. If I'm a bit groggy or not focused, my habits allow me to test my blood glucose with fewer mistakes.
Sanna Obermiller, Ruidoso, N.M.

Penny-Wise Decisions

I have been a type 1 diabetic since 1964 and I am conscientious about controlling my blood sugars. I am fortunate to have insurance that covers most of my diabetes-related expenses. However, insurance companies seem to make decisions that save a dollar today and cost thousands later.

In the past, my doctor was allowed to prescribe six to eight test strips daily. Now my insurance company will cover only four test strips per day unless I am on the pump.

Fifteen years ago I had to fight tooth and nail with my insurance provider to gain coverage for an insulin pump. The insurer argued then that my control was so good that I didn't need a pump. I finally got a pump, but eventually had to abandon it because of skin rashes at the insertion sites. I find it ironic that I can achieve excellent control without pumping, which is cheaper, and my insurance company now wants me on the pump. Readers, you are your own best advocate.
Tom McLaughlin, Portland, Ore.

Meters and Cold Weather

I have had type 1 diabetes for 29 years now and share your letter writer's frustration about meters that can't withstand cold temperatures ["Temperature Ranges for Meters," April '09, p. 14]. I live in New Hampshire, am an avid snowmobiler, and deal with temperatures that often drop below 10 degrees Fahrenheit. Being able to accurately check my blood sugar, while operating a snowmobile in the backcountry, is vital.
Tom Witmer, Epping, N.H.

I felt that your response to the Mail Call letter asking about operating temperature ranges for blood glucose meters was inadequate.

While "most blood glucose monitors operate within a wide temperature range," as you wrote, the examples you gave all only operated starting at 50 degrees Fahrenheit. Those of us who live in cold-weather locations have reason to be concerned about how our monitors will operate when the temperature drops. The FreeStyle meter that I use will operate in temperatures from 40 to 104 degrees, and the OneTouch operates between 43 and 111 degrees. All blood glucose meters do not have the same operating temperature ranges. This is important when you hike or play golf in the fall.
Jerry Zaug, Sister Bay, Wis.

Belinda Childs, MN, ARNP, BC-ADM, CDE, responds: Most glucose meters present two different temperature ranges: safe operating temperatures (the ones you cite) and storage temperatures (-4 to 140 degrees for the FreeStyle Lite, for instance). The owner's manual will also list the safe temperature range for test strip storage and use, plus the acceptable humidity and altitude ranges, which vary among meters. Use the meter's control solution to verify that its results are accurate.

The lowest operating temperature for most meters is 40 degrees. In extreme cold, keeping supplies and devices close to your body's heat will prevent them from freezing. The product's manufacturer and your diabetes educator or physician may be able to suggest ways to improve accuracy in extreme temperatures. In hot weather, a number of products can help keep your meter, test strips, and other supplies cool, such as Frio packs, wallets, and pump cases, which stay cool for up to 45 hours after applying water.

When traveling, hiking, or otherwise using your supplies outdoors, you should:

• Always carry extra insulin, glucose monitoring supplies, treatments for hypoglycemia, and food.
• Learn your equipment's operating temperature ranges. Take a control solution to check accuracy.
• Know whether heated shelter will be available if it's cold outside and whether you’ll have water to wet your pack when it's hot.
• Take urine test strips with you in case you have no other way of testing.

If you suffer from hypoglycemia unawareness, or are concerned about your supplies not working in extreme temperatures, travel with a buddy who is prepared to handle a diabetes emergency.

What does it take to stop diabetes? You!
This is your chance to tell the world why you want to stop diabetes, once and for all. 

In November, the American Diabetes Association will launch a movement to Stop Diabetes: to stop it from stealing moments, hours, and days from millions of people affected by diabetes. To stop the anxiety, fear, and heartache it causes every day. To stop the blindness and amputations. To stop discrimination against people with diabetes. And to stop it from haunting our children's future—and stealing our loved ones all too soon. 

To start this movement, we need your help. Why do you want to stop diabetes? What are you doing to stop diabetes right now? Let us know, and your story could be featured on the Web, used in promotional materials, or published in a future issue of Diabetes Forecast.

E-mail your story and, if possible, a photo of yourself to sharemystory@diabetes.org. Submissions are due by Oct. 15, 2009. Stories should be no longer than 200 words. Your story may inspire thousands of others to get involved to help stop diabetes!

Clarification: The Diabetes Review and Healthy Steps programs described in "Reaching Out for Assistance" (Aug. '09, p. 60) were designed to bring free education to people with diabetes and are funded and coordinated by Great Lakes Medical Supply in Warren, Mich., in collaboration with the American Diabetes Association.