Anniversary Cheers

Your fine 60th anniversary issue (Oct. ’08) reminded me of the first time I heard of Diabetes Forecast, more than half a century ago. In 1952, an employee of the American Consulate in Medan, North Sumatra, who had diabetes asked me to send him the magazine when I returned to the United States. I do not know how he had learned of the magazine, perhaps at the U.S. Information Agency library. But only 4 years after your founding, Forecast’s reputation had reached halfway around the world. Congratulations and thanks for your great international educational outreach!
James W. Gould, PhD
Cotuit, Mass.

What an excellent article: "Long Lives, Lived Well" (Oct. ’08, p. 54). The personal stories were inspiring and motivational. I enjoyed each one and was so glad these individuals shared their insights. There is something to be learned from experience shared.
Greater than that was the succinct history of diabetes and its treatment over the years. Thank God for researchers and their patience in their painstaking efforts to better the lives of people with diabetes.
I could identify with many of the personal challenges of the people featured. I have had diabetes (type 1) for 52 years and am happy to say I have had a very full life, and I’m still going strong.
Sister Virginia Murphy
Fond du Lac, Wisc.

Thank you, thank you, thank you, for writing an article about Jay Cutler, quarterback for the Denver Broncos. I have been a Broncos fan for as long as I can remember. I, too, was diagnosed with type 1 diabetes: I was 26 when I was diagnosed in November 2007, just 5 months before Jay’s diagnosis. I found out a couple of weeks after attending the Denver Broncos vs. Green Bay Packers football game. My heart went out to Jay when the news broke of his diagnosis, especially when some of the media didn’t understand.
I’m also encouraged by him because he will bring more awareness to the disease, and he shows that you can still do absolutely anything, even if you have diabetes.
Robynn R. Hickert
Hays, Kans.

Health Care Needs Improvement

With this letter I want to raise a couple of issues I have not seen addressed in your publication. It concerns a major lack in how we now diagnose and treat type 2 diabetes.   Fasting blood sugar is the primary tool now used to diagnose type 2. And, to be sure, if a person fails a fasting blood sugar test that person very likely has a problem.
But I believe this misses many of the people who have type 2. I am an example. I have never failed a fasting blood sugar test, and yet about 10 years ago I was diagnosed with type 2 diabetes. Prior to this, I had been having increasing problems with various types of bacterial infections, starting when I was 13 (I am now almost 56). Since the diagnosis and my ensuing control of my blood sugar, I have had no infection problems. And I control my blood sugar without medications.
I wonder how many millions of people are in the same boat as me. How many heart attacks, strokes, kidney failures, various infections, and more have occurred because of undiagnosed blood sugar problems?
The other serious problem is the way many doctors deal with a conventionally diagnosed type 2 blood sugar problem. Many simply prescribe medication. There’s no talk about checking blood sugar, no talk about how diet and exercise may help or even solve their problem. It’s just “what’s the symptom? Here’s the pill.” Invariably, many of these people do not do what they really need to do in order to control their blood sugar and they get worse—even with medication.
This sort of diagnosis and treatment is bad medicine and detracts greatly from how much healthier we could be as a nation. We can do better.
Michael Lee
Colorado Springs, Colo.

David Marrero, PhD, responds: While the fasting plasma glucose test is the preferred method of diagnosing diabetes due to its ease and low cost, a test that might catch cases like yours is the oral glucose tolerance test. However, since this is a difficult test to do, the ADA and other groups are looking at the A1C test. While the A1C test is not yet recommended for diagnosing diabetes, it may be a good way to catch the person who is hovering between pre-diabetes and diabetes and may become the standard for diagnosing diabetes in the future. Your points about diet and exercise to control diabetes are also important. In addition to diet and exercise to control diabetes, another current treatment recommendation includes starting metformin upon diagnosis of type 2. Patients should discuss with their health care providers the importance of all these things in combination.

Taking the Test

I have type 1 diabetes and was interested in your diabetes math test ("This Is a Test," Oct. ’08, p. 51). I apparently answered question 3 incorrectly; I calculated an answer of 30 grams of carbohydrate. The question asked: If you ate 1½ cups of the food labeled below, which would be two servings, how many grams of carbohydrate did you eat? The literal answer is 36 grams (18 grams of total carbohydrate times two servings), but since the example also shows that the dietary fiber is 3 grams per serving, I subtracted a total of 6 grams. This is what I use for calculating my insulin bolus for my pump. Am I incorrect, or is this a misleading question? I was under the impression that dietary fiber cannot be metabolized and thus should not be considered in carbohydrate calculation.
Greg Ohlson
Glendale, Ariz.

Sue Robbins, RD, CDE, responds: The question in the test only asks for total carbohydrate, without regard to fiber. So, the answer is indeed 36 grams. But your point is a good one. Fiber is a carbohydrate that is not fully absorbed by the body. Until recently, dietitians recommended subtracting the grams of fiber from the grams of total carbohydrate if a serving contained 5 or more grams of fiber. Newer research indicates that the body is able to break down about half of the fiber through anaerobic fermentation. The current recommendation is to subtract half of the grams of fiber from the total carbohydrate if the food contains 5 or more grams of fiber per serving.
Take, for example, a food that contains 36 grams of total carbohydrate and 6 grams of dietary fiber. From the 36 grams of total carbohydrate, subtract 3 grams (half the amount of dietary fiber), and you will end up with 33 grams of carbohydrate. You might also check your blood glucose to find out the effects of fiber on your own body.

Tips for Athletes with Pumps

I read with great interest the article in your September issue titled "In It to Win It" (p. 46). The story is about a college baseball catcher named Heath Pugh, and in the article it says he wears his insulin pump during his baseball games.
I am writing because my son, Dillon, age 14, also plays baseball (and basketball) but is afraid to wear his insulin pump during games. Any extra information you could give me about wearing pumps during games would be very much appreciated.
Gwen Boyer
Johnstown, Pa.

Belinda Childs, MN, ARNP, BC-ADM, CDE, responds: Wearing the insulin pump during sports can be challenging. What works for one person may not work for another. Here are some tips that have worked for my patients:
Depending on your particular situation and treatment plan, it may be best to leave the pump on during sports games and practices if possible. When off the pump, you will become insulin deficient within 60 to 90 minutes. A study published in the February 2008 issue of Diabetes Care shows that blood glucose rises 1 mg per minute when disconnected from an insulin pump for more than 30 minutes.Many of the pump manufacturers sell pump cases, including hard sports cases, waist belts, cases that strap to the thigh, and harnesses that allow the pump to be worn between the shoulder blades. Depending on the sport, a belt or a harness may be more appropriate. For soccer, softball, or baseball, it may be best to wear the pump in a waist belt with the pump in the small of the back. The needle may be best placed in the hip or lower abdomen. Additional padding could be placed under the pump to prevent bruising if the pump is hit hard. For basketball or volleyball, the harness that criss-crosses in the small of the back may be better.
Young women often pin pumps into the backs of their sports bras. One football player in our practice cut a hole the size of his pump in his thigh pad and put the pump inside. This also kept the tubing off his waist as it went down his leg to the thigh pad.
Using an intravenous skin prep is important to keep the skin from becoming irritated and to increase the adherence of the needle and tape. You might need to use Mastidol to increase the adherence of the needle, or use an extra clear dressing over the top of the needle for security. A needle that goes in at a 30- to 45-degree angle rather than a 90-degree angle may also work better for an active person.
It is important to have an alternative plan should the needle become dislodged or should the pump become damaged during an activity or when disconnecting. Be prepared in case your pump is lost or stolen. I had one patient who had a pump stolen out of a school locker. An alternate method of administering insulin should always be available by either insulin pen or syringe.
Finally, glucose monitoring is the key to managing the insulin pump and achieving near-normal blood glucose levels. It helps to ensure that athletes are performing at their optimal potential.