Managing Pre-Diabetes

I was interested to read Jessi Berger's letter (Mail Call, Dec. '08, p. 16) asking for more information about pre-diabetes. I was diagnosed with pre-diabetes 2 years ago. Having cared for a diabetic spouse for 30 years, I am somewhat familiar with the disease. My plan for combating pre-diabetes has been to follow a simplified diabetes program. My diet and exercise regimen is one that someone with diabetes might follow, and I measure my blood sugar every morning after 30 minutes of exercise and before breakfast. Following this plan, I have an A1C today that is less than 6.
Robert Kaiser
Tucson, Ariz.

Relating to Reflections

I could really relate to Dayle Kern's  Reflections piece, "One Story at a Time" (Dec. '08, p. 96).

My daughter, Michelle, was diagnosed with type 1 diabetes in February 2007 at the age of 16. Like Kern, we also were shocked and overwhelmed by all the new information that came with Michelle's diagnosis. She has gone from needle to pump back to needle a few times, trying to find the best control for her lifestyle. 

Michelle is now living with her diabetes in college, so for Christmas, I tried to get her something that would help her manage her diabetes out on her own. One gift was a diabetes cookbook.

Michelle sat quietly over the cookbook, flipping through the pages. I asked her what was the matter, and she asked me why I bought her the book. She told me that the reminder of her diabetes made her sad. I explained that I was trying to give her tools that would make her life easier.

As a parent, it is heartbreaking to know your child has these feelings. She often asks, "Why me, Mom?" and I have no answer.
Lynda Lynch
Port Huron, Mich.

Keeping Mail-Order Meds Safe

I read with interest the letter from G.A. Danner in the November issue (p. 18). Since being diagnosed in 1996, I have only had a couple of deliveries from mail-order pharmacies that were for some reason delayed extensively in the delivery process instead of coming via overnight delivery. In both cases the mail-order pharmacy did send a replacement delivery after I complained that the insulin package was no longer cool when it arrived.

However, I recently changed my medical coverage for financial reasons. As I have done with other insurers, I attempted to set up my insulin deliveries through the mail-order service. To my complete surprise, my new insurer will send out medical supplies only via the U.S. Postal Service, and clearly states that the supplies will arrive in 3 to 4 days. Because these deliveries occur in an area of the country where outside temperatures can easily be around 90 degrees or above for much of the calendar year—and who knows what temperature in the delivery trucks and post offices—I immediately asked about overnight delivery for temperature-sensitive medications such as my insulin. I was told I had no alternative for mail-order purchases.

I live in a private community with a post office that is also privately run, and our packages can take up to a week to arrive. I had no alternative but to arrange to make the more than 60-mile trip to the nearest pharmacy covered by my insurance provider to pick up my insulin supplies. It would be helpful to know what, if anything, can be done about a policy like this.
Charles Patterson
Pine Mountain Club, Calif.

I too have to call and complain to my mail-order pharmacy, and I have rejected at least three shipments from them. I was told they don't have to call me to let me know when the order will arrive. I have been told to "just reorder," but then there's the time element involved. Shouldn't the suppliers and shippers have some kind of quality control?
J.T.
Blackfoot, Idaho

Foot Treatments

I read a letter in a previous issue about a person with diabetes who lost a toe after wrapping it because of a toenail problem (Mail Call, Oct. '08, p. 18). The letter writer was prescribed oral and intravenous antibiotics but obviously to no avail. My question: Why was this person never given hyperbaric oxygen therapy? HBOT is a proven benefit for this type of problem (and others).
Raymond Owens 
Anchorage, Alaska

Lee Sanders, DPM, responds: HBOT is costly and remains controversial with respect to wound healing. HBOT is not a substitute for conventional methods of treatment, but it is an option in certain situations requiring medical and surgical treatment of lower-limb wounds in people with diabetes. It is reasonable to use HBOT to treat severe limb-threatening wounds that have not responded to other treatments. It may also help the healing of foot ulcers in patients with critical limb ischemia that cannot be corrected by vascular surgical procedures. However, in the presence of a severe foot infection, HBOT may be of no benefit, and amputation of a toe or part of the foot may be necessary.

I read with interest the "Ask the Experts" on toenail fungus by Lee Sanders, DPM (Dec. '08, p. 19). In 1996, after 31 years with type 1 diabetes and after many years of ingrown toenails and fungus problems, I asked my podiatrist if I could simply have my toenails removed. He said, "Sure." I wondered why he hadn't suggested this long ago if it was so simple, and as it turned out, it was very simple and marvelously successful. Now I wonder why it wasn't mentioned in this article. I would recommend it to everyone.
Jonathan Rupprecht
Milwaukee

Lee Sanders, DPM, responds: Surgical removal of one or more toenails for permanent correction of recurrent ingrown toenails or deformed fungus nails is commonly performed and relatively safe. The procedure is performed in an outpatient setting, most often in the podiatrist's office, under local anesthesia. It is very important that a person's diabetes be in good control before undergoing any surgery. People who have peripheral arterial disease should be particularly cautious in pursuing this option.

Finding "Success" in Running

In regard to Tracey Neithercott's article "Success" (Dec. '08, p. 61), I would love to have more information about Jerry Nairn's training program. I have had diabetes for 19 years, and my A1C is 6. I am interested in learning how Nairn found other diabetic runners, what his training program is, what he carries with him, whom he runs with, how he adjusts his pump, what he eats before he runs, etc. Any suggestions would be helpful.

Thanks for covering this topic. In fact, I recently commented to my husband that I wondered if there were any diabetic marathoners. I would love to know how to tackle this challenge.
Dena L.
Houston

Associate Editor Tracey Neithercott responds: Jerry Nairn ran his first marathon in 1998 and has been running marathons ever since. To prepare for the 26-mile races, Nairn logs 30 to 50 miles a week and often runs with friends and family. When he runs long distances (more than 10 or 12 miles), he carries a blood glucose meter with him.
On race day, Nairn eats a meal about 3 hours before he plans to run, and if his blood glucose level drops too low before the race, he'll eat an energy gel. Before the race starts, he turns down the basal rate on his insulin pump and checks his blood glucose levels. He also checks his glucose levels at the race's halfway point when running a long race, like a marathon, and then again after he's crossed the finish line. For safety, Nairn carries glucose tabs and energy gels in his shorts pockets, and always wears a medical alert bracelet.

Nairn met other marathoners with diabetes through ADA's Team Diabetes and online at www.insulindependence.org. But note: Diabetes—and exercising with diabetes—is different for everyone, and you should talk to your health care providers before you embark on an intensive exercise regimen. Another important thing to note: Nairn has been running for years, so you shouldn't expect (or aim) to immediately follow a regimen like his. Start at a slower pace and work your way up.

Vitamin K Still a Good Idea

I am somewhat concerned about a statement in the article "K Packs a Punch" (Dec. '08, p. 31). The statement reads, "People taking the anticoagulant drug Coumadin need to avoid vitamin K."

When my husband first started taking Coumadin in 2003, he was asked if he liked spinach. He said that he did and that he ate it at least once a week. The doctor said that was fine, just to stay on the same course he was on and to not make any drastic spinach additions to his diet. The booklet accompanying the drug said the same thing. My husband has done just fine since then. We recently spoke with a friend of ours who was under the impression that he couldn’t have not only spinach but even salad. Someone needs to clear this up.
Sheila Horst
Mount Prospect, Ill.

The Editors respond: It's true that when taking Coumadin (warfarin), you don't need to avoid vitamin K altogether, but you should avoid large weekly fluctuations in dietary vitamin K intake.

In other words: Consistency is key.

People taking Coumadin should also carefully review the contents of nutritional supplements and vitamins for vitamin K content. Coumadin blocks the action of vitamin K on blood clotting. Large increases in vitamin K levels may increase the chances of clotting, and large decreases in vitamin K levels may increase the chances of bleeding in people taking Coumadin.

Large fluctuations in intake may result from eating foods high in vitamin K such as spinach, kale, and a variety of greens, including turnip, collard, beet, dandelion, and mustard, especially the frozen, packaged versions.

Inform your doctor if you eat more vitamin K–rich foods when produce is  plentiful in the summer; your doctor may adjust your Coumadin dosage. Information about the vitamin K content of common foods should prove helpful in monitoring your intake. For example, 1 cup of frozen spinach (cooked and drained) contains more than 1,000 micrograms (mcg) of vitamin K. Broccoli, brussels sprouts, cabbage, and asparagus contain about 150 to 300 mcg per cup. And one head of iceberg lettuce has 130 mcg.

Many other fruits and vegetables contain less vitamin K. The vitamin K content of a large number of foods can be found in the USDA National Nutrient Database for Standard Reference, Release 21 at www.nal.usda.gov/fnic/foodcomp/search/.

Corrections: Due to reporting errors in the 2009 Resource Guide, the Nipro Amigo insulin pump was omitted (Jan. '09, p. 49). An updated chart that includes the Amigo is available at forecast.diabetes.org/files/images/Insulin PumpChartREV.pdf. In addition, the blood sample sizes for the Eclipse and Element glucose meters were swapped (p. 56).
The Element uses a 0.3-microliter drop of blood; the Eclipse requires 1.0 microliter.

A feature for the TrueResult blood glucose meter was mistakenly listed (p. 60). This meter does not twist onto the top of a test strip vial. It was incorrectly stated that the Pelikan Sun Electronic Lancing Device uses a range of needle gauges (p. 65). The device uses a disposable disk of 50 lancets. The One Touch UltraMini was listed with an inaccurate memory size (p. 58). The meter holds 500 past glucose tests in its memory. Finally, the OneTouch UltraLink meter wirelessly communicates only with the MiniMed Paradigm 512/712, 515/715, and 522/722 insulin pumps.