Happy Birthday, Diabetes Forecast

The 60th anniversary issue (Oct. ’08) is a keeper for me. January 2009 will be my 60th anniversary of living with diabetes. No one can forget those glass syringes—which I carried in alcohol—or the No. 14 needles. The introduction of home blood glucose monitoring was really a blessing. The advent of distinguishing between type 1 and type 2 diabetes explains why a doctor had me take two medications in addition to insulin for a week, before he realized that I had type 1 diabetes. The first Forecast I looked at was primarily for medical professionals. Today I find the magazine very interesting and informative for me, too.
Carl Weinert
Tucson, Ariz.

When I received my October issue I was surprised to find out that Diabetes Forecast and I have something in common—we were both born in 1948! On December 10, I will also turn 60. I enjoyed the anniversary issue and look forward to many more years for both of us.
Noralee Horn
Abilene, Texas

As a 21-year-old college student who has had diabetes for 8 years and sometimes worries about the future, I want to thank you for the “Long Lives, Lived Well”  article (Oct. ’08, p. 55). It gives me great hope that someday I will be able to have a grandson or granddaughter sit on my lap.
Brennan Cassidy
St. Paul, Minn.

The 60th anniversary issue is a very informative and especially interesting issue—including the history of diabetes and its technology, the interviews with people who have had diabetes for 60 years, the future medications and treatment coming down the “pipeline,” and the Diabetes 101 math quiz (“This Is a Test,” p. 51). I am a former certified diabetes educator and took the test and completed it with interest.
Phyllis Jones
Gibsonia, Pa.

Evening Meals, Morning Glucose

I just finished reading the answer to a question put to “Ask the Experts,” answered by Roger Austin, a pharmacist (“Unexplained High Blood Glucose,” Aug. ’08, p. 18). I have been a diabetes educator for only 3 years. However, we learned in our education that all food eaten the night before, no matter what time, even as late as 10 p.m., has been digested by morning. Then the blood sugar rises, but drops back to whatever is “normal” for the patient by the time he or she wakes up. Early morning highs are caused by the dawn phenomenon or by not taking enough medication, not by what was eaten the night before. Also, I agree exercise is important any time of the day, but how is exercising in the evening going to lower morning levels?
Nancy Smith, MS, RD, LD/N, CDE
Jacksonville, Fla.

Roger Austin, MS, RPh, CDE, responds: The key words here are “whatever is normal for the patient,” given that he or she has type 2 diabetes. Because patients with type 2 have delayed or insufficient insulin production in response to a meal, their post-meal glucose may still be elevated, even though the meal has been digested, and the carbohydrate content in the meal consumed has been converted into glucose. When insufficient insulin is produced overnight—which is the case with most people with type 2 diabetes—the liver releases more stored glucose, causing blood glucose levels to go up so that the fasting glucose is high in the morning. Regarding exercise: There is a “carry forward” effect that can sometimes lower blood glucose as long as 24 hours after exercise. 

Learning Average Glucose

The table of estimated average glucose (eAG) values in the August issue (p. 21) looks very useful, especially as my endrocrinologist and I are trying to make sense of the current ADA table (an A1C of 7 being equivalent to a fingerstick of 170, for example) relative to my own A1C and average fingerstick results. But I am wondering: Are the eAG figures based on whole blood or plasma results?

Until April 2007, most of my fingerstick results were generated with a meter calibrated against whole blood. At that point, my endrocrinologist suggested using a more modern meter, which happened to be calibrated against blood plasma.  I was cautioned that the new meter’s results would be 12 percent higher than whole blood results, and there certainly seems to have been a modest rise in my fasting blood sugars, for example. In the A1C range of 6 to 7, which is where my body usually lives, that 12 percent difference is 15 to 18 points and equivalent to a 0.5 difference in A1C results, so the 12 percent is significant.
Stan Fairchild
Rocky River, Ohio

Paris Roach, MD, responds: The devices used to monitor blood glucose in studying the relationship between A1C and blood glucose concentrations were plasma-referenced. Thus, the blood glucose concentrations shown in the table are plasma-referenced.

Lessons from the July Issue

I want to thank you for publishing the article “The Truth About Pedicures” (July ’08, p. 46).  I was contemplating getting a pedicure and after reading the article, I decided a pedicure was not worth the risk. I also enjoyed reading an article on pop star Nick Jonas (July ’08, p. 34).  He was courageous to inform his fans that he has diabetes. He has a great voice and is a good role model for people with diabetes his age. People like him can achieve a dream and manage diabetes at the same time.
Katie Ahlers
North Yarmouth, Maine

Generic Insulin, Test Strips?

I have health insurance through my employer and picked up prescriptions today for two bottles of Humalog 100 ($56) and three bottles of Lantus ($80), and I wondered, why even have insurance? These prescriptions have each increased $20 over the past 2 years. There seems to be no relief in sight.

I have had type 1 diabetes for more than 40 years, and the costs of insulin and meter test strips ($86 for 100 strips), even with insurance, are clearly out of hand. I wonder if you would be interested in updating the public about when we can expect to have access to generic insulin and meter test strips as they are much more affordable.
Kelli Lewis
Moses Lake, Wash.

Belinda Childs, ARNP, MN, CDE, BC-ADM, responds: Insulin falls under different patent laws than most medications because insulin is considered a “biological” product rather than a “chemical” product like metformin or other oral medications. These laws, to date, prevent companies from obtaining licensing to produce generic insulins. It’s worth noting that the analog insulins like Lantus, Levemir, Apidra, Humalog, and Novolog are more expensive than the older human insulins like NPH and regular. In addition, Wal-Mart packages the Novolin brand regular, NPH, and 70/30 insulins under the lower-priced ReliOn brand. A 10-ml vial sells for approximately $20. You may want to speak to your diabetes care provider to see if you are a candidate for treatment with one of these less expensive insulins.

The higher prices that you are seeing at the pharmacy are primarily related to increased costs for manufacturing and transportation. The increasing co-pays, meanwhile, are driven by the purchaser of your health plan. To help prevent an overwhelming increase in the premium that you pay or your employer pays, co-pays for medications and office visits are often increased, which is what I suspect has caused the increase in the cost of your insulins.

The second part of your question relates to the cost of glucose strips. I have been in this business since 1979, when blood glucose meters were just being introduced. The total cost of my brother’s first meter in 1980 was $700, which included his first bottle of 100 glucose strips. Fifty strips in 1980 cost approximately $60. So the cost of strips has not really increased in nearly 28 years (and the cost of meters has declined dramatically). That said, there are some generic meter and strip alternatives that may allow you to decrease the cost of your glucose monitoring supplies. You could speak to your pharmacist or diabetes educator about these alternatives.

Prevention Is Key

I was recently diagnosed with prediabetes and have been reading your magazine in order to better educate myself about what I can do now to prevent or delay developing diabetes in the future. With the millions of Americans who have pre-diabetes, I am a bit disappointed to see that you have no information in your magazine about this illness. When I was diagnosed, I had a lot of information thrown at me in a short amount of time, including the phrase “when you get diabetes.” Finding information on pre-diabetes has been like looking for a needle in a haystack. Would you please consider adding a section to your magazine for people with pre-diabetes that focuses on education and prevention?
Jessi Berger
Kirksville, Mo.

The Editors respond: Thank you for drawing attention to this important aspect of care. Although you may not see it named specifically as “pre-diabetes” material, Diabetes Forecast regularly runs pertinent content about diabetes education and prevention in our “Step One” exercise column and “Food for Thought” healthy eating column, as well as in the Forecast section and in feature articles. Although the majority of our readers already have diabetes, we think there is a lot of material in the magazine that can be of help to people with pre-diabetes—or those who just want to live healthier lifestyles—too.