Missing Exubera

Exubera made a difference in my life, and I am disappointed that Pfizer is taking it off the market (Dec. ’07, p. 19).

I was skeptical when I first started using Exubera, but the advantages of inhaled insulin were great for me. I had much better control, with only a few lows and highs.

I did not have to worry about how the inhaled insulin got absorbed into my system the way I used to worry about my insulin absorption rate with injections. I also got rid of the bruising on my arms where I used to administer my shots.

Exubera acted just as quickly as injectable insulin, for me, and I experienced no decline in lung capacity. I hope that in the future, more people will be able to try inhaled insulin, because it really does work.

Marianne Evans
Highland, Utah

Playing Hardball

I love Chris Matthews’s Hardball program. I appreciate his forthrightness in talking about his experience with diabetes (Dec. ’07, p. 40). But it is unfortunate that he “doesn’t have time” to utilize one of the better medicines freely available to him: exercise.

Regularly scheduled cardiovascular activity (4 to 6 days per week) and weight-lifting exercise are critical. Exercise improves cell function in ways manufactured medicine can’t.

Gary R. Taylor
Via the Internet

This is the first time that I’ve read Diabetes Forecast, and I can relate to your article on Chris Matthews. For a few years, I was drinking too much soda and eating too many sweets, and I was worried I was at risk for diabetes. Then I started running, eating healthier, and drinking less soda. Chris Matthews is one of my favorite people on television, and I am glad that he was willing to discuss his diabetes and share how he’s managing it.

John Huerta
Warren, Ark.

Snore No More

Thank you so very much for the article about sleep apnea, “Is It Just a Snore?” (Dec. ’07, p. 51). I didn’t know anything about it until I went through a sleep study a few months ago. I was sleeping a lot through the day, and at first attributed that to my diabetes. But I learned that because of my sleep apnea, I was waking myself up over 200 times a night. I could have died any given night. I was hardly sleeping at all. Now that I have the CPAP machine, I sleep much better and feel much more rested.

I don’t understand why this is not discussed more. Sleep apnea is nothing to be ashamed of.

Jan Carder
Via the Internet

My wife, a registered nurse, encouraged me to read Chris Matthews’s account of his struggle with recognizing and controlling his diabetes, and then to top it off, Diabetes Forecast ran an article on sleep apnea. I’d love to have interviewed Chris Matthews to inquire about his sleep health prior to his weight loss and ensuing vigilance. The hallmark signs and symptoms of sleep apnea are all that your article suggested, in addition to a few others that may present as comorbidities—notably hypertension of an unexplained or increasing nature.

Finally, I further commend your article in that you not only included the two classic treatments for diagnosed obstructive sleep apnea, CPAP and surgical consideration, but also recognized a third—an oral dental appliance. Indeed, dentists can play an important role in working with a patient’s family physician to ensure comprehensive recognition and treatment options. They should also be encouraged to contact their nearest sleep medicine clinic so that patients get access to all available treatment options.

Jerry A. O’Ryan, BS, RRT, RCP
President, Physicians Sleep Diagnostic Centers
Centerville, Ohio

Good or Bad

In the article “Good, Bad, and Ugly” (Dec. ’07, p. 36), Dr. Shauna Roberts writes that one should cut down on meat, cheese, and eggs. In addition, she recommends increasing whole grains, fruits, and vegetables. She only mentions the need to decrease carbs and alcohol if your triglycerides are high. This is correct regarding the triglycerides; however, you can have low triglycerides and high LDL and still have diabetes.

As a result of decreasing protein and increasing carbs, glucose will go up. The most recent research on eggs indicates that, in moderation, they do not increase LDL, and they can assist in weight loss. They also increase satiety, and are a great source of protein. I usually recommend the high-omega-3 eggs as a source of omega-3 fats for my patients, as many do not like fish, flax, and walnuts (other sources of omega-3).

Why not just try lean baked meats and low-fat cheeses (in addition to the whole grains, beans, peas, etc.) rather than a blanket assumption to cut back on all meats and cheeses? I find this odd when there is a possible association with recent research in dairy and weight loss. High-carb skim milk might work well for people with type 1 diabetes, but for the significantly insulin-resistant type 2s, who make up most of my patient population, this diet would compromise glycemic control. I find many of my patients have excellent LDL reduction on statins, but continuously struggle to get their A1C within range even on multiple oral agents.

Millicent Meeks, MS, RD, CDE
Via the Internet

Shauna S. Roberts, PhD, responds: As you know, the diet that is considered best for heading off heart disease, cancer, and some other chronic illnesses is one that is high in vitamin- and phytochemical-rich plant foods. However, these foods are also high in carbohydrates, which add glucose to the blood. Thus, the choice of diet for people with diabetes involves a tricky balancing act between improving blood glucose control and reducing health risks.

The American Diabetes Association’s clinical practice recommendations weigh in on accomplishing this balancing act. I will cite two key recommendations:

• For patients with diabetes who are at risk for cardiovas­cular disease (which includes most people with diabetes), diets high in fruits, vegetables, whole grains, and nuts may reduce the risk.
  
• The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances.

ADA acknowledges that different people do best with different diets.

You are correct that lean baked meats and low-fat cheeses are exceptions to the generalization that meats and dairy products are high in cholesterol. The list of foods in that sentence was meant to give the reader a few examples of high-cholesterol foods, not to provide a full discussion of high- and low-cholesterol foods.

This piece was too brief to go into omega-6 fatty acids and omega-3 fatty acids, let alone the benefits of the new eggs that are high in the latter. However, omega-6 and omega-3 fatty acids would make an interesting and useful topic for an article, and I’ll keep it in mind for the future.

Taking a Stand on Stem Cells

I appreciated [ADA Executive Vice President of Government Affairs and Advocacy] James Schlicht’s response to the Mail Call letter critical of stem cell research (Jan. ’08, p. 12). In addition, I would like to take strong exception to the reader’s letter, which said “the ADA should … stay out of politics.”

It is moral and proper for the ADA to advocate in the political arena because a primary responsibility of government, and thus the political system, is to protect and care for its citizens.

The most significant amount of research dollars for health come from our government. The distribution of these dollars is affected by the political arena. The health of all Americans, and the world, is a most important political issue. I think urging the ADA to stay out of politics is not only naive, but also harmful to diabetics.

Thank you, ADA, for advocating for us. Thank you also for seeing clearly the need for ethical stem cell research, as James Schlicht’s response makes clear.

Rev. Dr. Larry W. Spielman
Victorville, Calif.

Full Coverage

In the Dec. ’07 issue (p. 11), David MacDonald writes a letter about “CGM Success.” MacDonald describes his success attaining insurance (coverage for a continuous glucose monitor, or CGM) “with the help of my team of doctors and after my persistent phone calls and letter writing.”

The doctor’s help part is self-explanatory, but my question is: Who was called, and to whom were letters written? I’ve had type 1 for 51 years, and I’m pursuing getting a CGM. Who do I write to or call?

John Compos
Via the Internet

Sue Kirkman, Vice President of Clinical Affairs, American Diabetes Association, responds: The ADA’s position on continuous glucose monitoring is that the technology may be useful as a supplemental tool to blood glucose monitoring with a meter for selected patients with type 1 diabetes, especially those with problems with severe hypoglycemia due to inability to sense these episodes.

Your own physician, because he or she knows your diabetes history and will be the one to prescribe the device, is in the best position to advocate for what he or she believes is medically necessary for the care of your diabetes. The initial action is generally a letter of medical necessity (LMN) from your physician to your insurance company. Most physicians are well acquainted with the LMN process. Your physician may also want to work with the manufacturer of the device he or she feels is best for you, as the manufacturers often have resources to facilitate obtaining coverage.

Each insurance plan has a process for appealing if coverage for a treatment or device is denied. If this happens, you could help your physician with the appeal by finding out what the process is, either by calling your insurer or checking on their Web site.

Other resources can help individuals with claims appeals in general. The Kaiser Family Foundation’s Consumer Guide to Handling Disputes with Your Employer or Private Health Plan provides step-by-step instructions on the best ways to appeal all types of claims decisions, including state-specific information on how to obtain an external review of the insurer’s decision. It can be found at www.kff.org/consumerguide/ 7350.cfm.