POWER OF
REVENTION
Vol. 2, Issue 2
THE GOOD NEWS ABOUT PREVENTING DIABETES COMPLICATIONS Page 2
ON PENS AND NEEDLES: What You Need to Know About Injectable Diabetes Medications Page 5
WHAT IS AN A1C TEST? Seems Like My Doctor Is Always Ordering It! Page 9
Planning for Your
HEALTHY BABY Page 12
New Tools in Shed
Page 7
POWER OF PREVENTION
Where We’ve Been; Where We’re Going
THE GOOD NEWS About Preventing Diabetes Complications
Page 2
B Y D O N A L D A . B E R G M A N , M D, FA C E Power of Prevention (POP) began in 2003. It had a simple plan: to help patients learn how they can prevent the complications of diabetes, hypertension, osteoporosis, and high cholesterol. Proper nutrition and physical activity are important parts of the plan, but medication is usually also needed to prevent complications. Medication alone without changing one’s lifestyle normally doesn’t work. Shortly after POP was announced at the 2003 annual meeting, a POP web site was launched. The web site now deals with many topics, including osteoporosis, thyroid disease, men’s endocrine health, women’s endocrine health, nutrition, parathyroid disorders, and lipids. Several months after the program was launched, POP joined the President’s Council on Physical Fitness and Sports. Together, a school program was designed that teaches children about metabolism and the importance of eating right and being active on a daily basis. That program is still available online at the same web site (www.powerofprevention.com). The program is easy to download and includes a Microsoft PowerPoint presentation aimed at sixth graders, a teacher’s guide to metabolism to be used the week before the PowerPoint presentation, and a letter of introduction which helps to get through the school security regulations. In addition to endocrinologists [en-doh-cri-NA-lo-jists], many teachers and individuals without any medical training who are interested in the health of our children have done this program. Give it a try! POP has recently turned its attention back to adults. A manual of physical activity was released in 2006 and a POP guide to nutrition (written by ~40 endocrinologists) will soon be available from Amazon and on Kindle. POP created a 5k fun run that is held at the annual meeting of the American Association of Clinical Endocrinologists (AACE). This run makes clear the need for endocrinologists to keep healthy so that they can keep you healthy. An exciting new project is the magazine that you are now reading. This is produced from time to time and is offered at no charge. It covers timely topics related to endocrine disorders. So far there have been issues on thyroid disease, obesity, and diabetes. The magazine may be offered on a more regular basis (every other month) in the future, and an online format is being developed (this year’s thyroid, obesity, and diabetes issues are available now at the POP web site www. powerofprevention.com). I would like to invite each of you to submit ideas for future issues of the POP magazine. What do you want to learn more about? Go to the POP web site and click on the POP magazine section. There is a place for you to submit your ideas. POP is dedicated to the idea that physicians should spend more of their time preventing illness so that they can spend less time treating illness. You can help by keeping your lifestyle healthy and helping others to do the same. Try going into the schools and presenting the POP school program to the children. Keep up to date by reading POP publications. You will feel better and your children will be healthier. When you think about it, what more can you ask for!
11 Window of Opportunity Read about how patient Sharon Beam came to terms with being diagnosed as diabetic and how she manages to maintain her active lifestyle.
TA B L E O F C O N T E N T S 8 Health Literacy
1 A Note from
the Guest Editors
Learn how to talk to your doctor and get the most out of your diabetes care
There is hope for people who have been diagnosed with diabetes
9 What is an A1C Test?
2 The Good News About preventing diabetes complications
4 Looking for a Healthy Heart? It’s more than just blood sugar! See our ten-step program.
5 On Pens and Needles What you need to know about injectable diabetes medications.
Read about the test your doctor always seems to be ordering for you
for Type 2 Diabetes
Stay on Track with Diabetes
Learn the value of a good night’s rest
Discover apps, web sites and internet resources that can help you
20 Depression: A Common and Treatable Condition in Individuals with Diabetes
11 Window of Opportunity
Healthy Baby
7 New Tools in the Shed Learn more about insulin, continuous glucose monitoring, insulin pumps, and glucose meters.
What you can do to optimize your care while you manage diabetes and pregnancy
14 How Much Should I Be Eating?
8 Endocrinologist: The Specialist in
Learn how to estimate your calorie intake and manage your weight
How does endocrinology relate to diabetes?
15 Family Ties
the Comprehensive Care of Diabetes
18 The Impact of Sleep
Disturbances on Diabetes
12 Planning for Your
Learn about new hormone therapy for the treatment of type 2 diabetes.
Having a hard time getting yourself to exercise? Learn how to overcome those hurdles and be healthier
10 Technology to Help You
Read about how patient Sharon Beam came to terms with being diagnosed as diabetic and how she manages to maintain her active lifestyle.
6 Incretins: New Treatments
16 Making Exercise Part of Your Daily Life
A patient story about the importance of family when dealing with diabetes
POWER OF
Read about symptoms and treatment
21 Vitamins, Minerals,
Supplements... Maybe A Potion or Two Would Work for Me? Taking supplements can be good or bad
22 The Power of Volunteering
for Clinical Research
Learn how choosing to participate in diabetesrelated studies can help you and others
24 Kidz Zone 26 Letters from Readers
REVENTION
POWER OF THE MAGAZINE
PREVENTION
Power of Prevention, published by the American College of Endocrinology (ACE), the educational and scientific arm of the American Association of Clinical Endocrinologists (AACE), is dedicated to promoting the art and science of clinical endocrinology for the improvement of patient care and public health. Designed as an aid to patients, Power of Prevention
DONALD C. JONES CHIEF EXECUTIVE OFFICER, AACE
includes current information and opinions on subjects related to endocrine health. The information in this publication does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other
AMERICAN COLLEGE OF ENDOCRINOLOGY
acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations
STEVEN M. PETAK, MD, JD, FACE, FCLM President, ACE
unique to the institution or type of practice may be appropriate.
BILL LAW, JR., MD, FACP, FACE President Elect, ACE
The ideas and opinions expressed in Power of Prevention
DONALD A. BERGMAN, MD, FACE Chair, ACE Power of Prevention Committee
responsible for statements and opinions of authors or the
do not necessarily reflect those of the Publisher. ACE is not
claims made by advertisers in the publication. ACE will not assume responsibility for damages, loss, or claims of any kind
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arising from or related to the information contained in this
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services mentioned herein.
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Material printed in Power of Prevention is protected by
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copyright. No part of this publication may be reproduced or transmitted in any form without prior written permission from
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Power of Prevention, except under circumstances within “fair
In the United States, about 11% of adults over 20-years-old have diabetes. This number is much higher in older persons and in those with certain ethnic backgrounds. A child born in this decade has a 1 out of 3 chance of developing diabetes. Serious statistics? Yes, but preventable. Studies have shown that even in people known to be at a high risk for diabetes, diabetes can be kept at bay in almost 60% of people with moderate physical activity for 150 minutes a week (30 minutes per day and 5 days a week) and losing 7% of body weight. The benefits of this study were still there 10 years after the start of the study. Studies in Finland and China showed similar benefits—lifestyle changes work to prevent diabetes!
P
It is exciting to see that there are fewer problems related to diabetes with the right medical treatment. Research studies prove that we can prevent many of the complications of diabetes by controlling blood sugar, blood pressure, and cholesterol levels. These benefits do require attention to details in many aspects of diabetes care. A team approach between you and your health care team can make this attention to detail work for you. Knowing what the goals are for you is a big start. Also, your team can work with you to achieve the best blood sugar and blood pressure control, as well as all the other things that need to be managed to prevent diabetes complications. Your team should be a resource for you for your questions and concerns, and the information you will find in this magazine will also help. In this issue of Power of Prevention Magazine, you will read about many important aspects of diabetes. This includes the latest research and tools that are helpful in controlling diabetes and preventing the problems that come from the disease. Many of the authors in this issue are endocrinologists [en-doh-cri-NA-lo-jists] (specialists in diabetes and hormonal disorders). Several of these authors have helped improve our knowledge of how to manage diabetes. Most of these authors are members of the American Association of Clinical Endocrinologists (AACE), a group of experts in diabetes and hormonal disorders.
We hope that you will find the information provided in this issue of POP helpful as you strive for the best of health!
info@aace.com, Web site www.aace.com.
FL 32202 • 904-353-7878 • Fax 904-353-8185 • E-mail
AACE is a professional medical organization with more than 6,000 members in the United States and 84 other countries. Founded in 1991, AACE is dedicated to the optimal care of patients with endocrine problems. AACE initiatives inform the public about endocrine disorders. AACE also conducts continuing education programs for clinical endocrinologists, physicians whose advanced, specialized training enables
AMY OGLESBY Graphic Designer
But, don’t worry: there is a lot of good news for people with diabetes. Diabetes can be managed and diabetes problems can be prevented. Why? Because we have made much progress in the past 20 years in knowing how to manage the disease.
Power of Prevention is published by the American College of
SARAH SENN Public & Media Relations and CAP Assistant
JEFF HOLLOWAY Graphic Designer
Have you just been told that one of your parents has diabetes? Or that your brother or sister has diabetes? Or maybe even you have diabetes? Are you thinking about your uncle with diabetes who had to go on dialysis, or your grandfather that lost a leg to complications from diabetes? Or a neighbor that lost his or her eyesight? You can guess that diabetes is a serious disease that can have many complications.
The people who have shared their thoughts on coping with diabetes in this issue have done so to inspire and help others with diabetes to take charge and live healthier lives.
Endocrinology, 245 Riverside Avenue, Suite 200; Jacksonville,
TRAVIS CHEATHAM Director of Graphic Design
Dear Reader,
use” as defined by US copyright law. © 2008 ACE.
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them to be experts in the care of endocrine diseases, such as diabetes, thyroid disorders, growth hormone deficiency,
ABOUT AACE AND ACE The American Association of Clinical Endocrinologists (AACE) has more than 6,000 members in the United States and around the world, and is dedicated to improving the lives of individuals with diabetes and hormonal problems. The American College of Endocrinology (ACE), joined with AACE, provides education to health-care professionals, and Power of Prevention is focused on education and motivation of individuals with diabetes and hormonal problems to have healthier lives. For further information visit www.powerofprevention. com and www.aace.com
osteoporosis, cholesterol disorders, hypertension and obesity.
CONTRIBUTING EDITORS NATHALIE A. TURNER, MS, ELS Medical Literacy Editor Obesity Issue, Power of Prevention Magazine
GUEST EDITORS
A Note from the
Thank you,
Dr. Etie Moghissi is board certified in endocrinology, diabetes and metabolism and is in private practice in Marina del Rey, California. She is a Clinical Associate Professor of Medicine at UCLA. Dr. Moghissi is a recognized expert in the field of diabetes and is actively involved in direct patient care, as well as in professional medical education. She has published in peer-reviewed medical journals including Endocrine Practice and Diabetes Care. She serves as Treasurer of the American Association of Clinical Endocrinologists, and is Secretary/Treasurer of the American College of Endocrinology. Dr. Dace Trence is Director of the Diabetes Care Center and Associate Professor of Medicine at the University of Washington Medical Center in Seattle. She is also the University of Washington Endocrine Fellowship Program Director and Director of Endocrine Days, a medical education program for endocrinologists practicing in the Pacific Northwest. She is on the American Association of Clinical Endocrinologists Board of Directors, and chairs the CME Committee.
ACE is a scientific and charitable medical organization dedicated to promoting the art and science of clinical endocrinology for the improvement of patient care and public health.
ETIE S. MOGHISSI, MD, FACP, FACE AND DACE L.TRENCE, MD, FACE Guest Editors
POWER OF PREVENTION • VOL. 2, ISSUE 2
1
THE GOOD NEWS About Preventing Dia betes Complica tions BY FARAMARZ ISMAIL-BEIGI, MD, PHD
of diabetes do not produce insulin, and their health and wellness depends on taking insulin on a regular basis. Two important studies (called DCCT and EDIC), which involved more than 1,400 volunteers with type 1 diabetes, have shown that good blood sugar control plays a very important role in preventing small vessel complications in the eyes, nerves and the kidneys. The results were so dramatic that doctors and patients all over the world started to aim for better blood sugar control. The studies have also shown that good blood sugar control can help prevent large vessel disease that can lead to heart attacks and strokes in people with type 1 diabetes.
“WHAT IS THE BEST WAY TO GET GOOD BLOOD SUGAR CONTROL? WHICH INSULIN REGIMEN IS BEST?” These are questions that each person should discuss with their health-care team. Today we have better insulins and better tools and technologies to help people get their blood sugars under control. Like everyone else, people with type 1 diabetes can develop a rise in blood cholesterol and fats (lipids), high blood pressure, and “hardening of the arteries” with increasing age. Attention should be given to controlling the harmful effects of these changes, as well as stopping smoking.
“WHAT IS TYPE 2 DIABETES AND WHO GETS IT?”
E
or legs, and even early death. It is important to know that all these complications can happen, even if you feel healthy.
So, you may ask,
The answer to this question can vary depending on whether you have type 1 or type 2 diabetes. However, no matter which type of diabetes you have, good blood sugar control is the most important way to prevent damage to small blood vessels. Also, as described further below, you can do many things to prevent the complications related to the large blood vessels.
very now and then, patients with diabetes ask me: “Doctor, even though most of my blood sugar numbers are high, I feel good. I don’t understand why I should take all these pills and insulin injections.” This is a great question. The main reason to have control of your blood sugar (glucose) is to prevent complications of diabetes. Diabetes, during its early years, produces no major symptoms unless the blood sugar gets very high. Then, the person will make a lot of urine, become thirsty, and not feel well. This is true in all types of diabetes.
“WHAT ARE THE COMPLICATIONS WE SHOULD PREVENT?” We classify diabetes complications into two categories: 1) Complications that damage small blood vessels in your body Diabetes can damage small vessels in the eyes, nerves, and kidneys. These can lead to blindness, loss of sensation in hands and feet, and kidney failure. These complications are serious, and can have a very negative effect on a person’s well-being. 2) Complications that damage the large blood vessels Complications that damage large blood vessels cause “hardening of the arteries” that feed your heart, brain, and body. These complications are also very serious and can lead to heart attack, stroke, loss of arms
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POWER OF PREVENTION • VOL. 2, ISSUE 2
“HOW CAN I PREVENT THESE COMPLICATIONS?”
“WHAT IS TYPE 1 DIABETES AND WHO GETS IT?” This type of diabetes (previously called juvenile diabetes) often starts in children and young adults, but it can start at any age. It begins after damage and loss of cells that produce insulin. For this reason, people with this form
This form of diabetes (previously called “adult-onset diabetes”) is the most common form of the disease. Currently, more than 20 million people in the United States have it. Type 2 diabetes is on the rise, and it is estimated that millions more people in the USA and across the world will be affected in the next 20 to 30 years. Type 2 diabetes can run in families and is increasing in children and young adults. We often see this disease in people who are overweight. Type 2 diabetes is not just a problem of blood sugars. It also affects blood pressure, cholesterol, and fats, inflammation in the body, and blood clotting. Normally, cells in the pancreas release proper amounts of insulin. This helps sugar enter into cells throughout the body for energy. One main problem of type 2 diabetes is the “resistance” of cells to insulin. This means that it takes more insulin to produce the same effect. On top of that, people with type 2 diabetes do not make enough insulin for what their body needs. In other words, there is also a problem with the cells that produce insulin. The tie-in with obesity comes from the fact that there is higher “resistance” to insulin with higher body weight. This brings us to the important role of nutrition and physical activity, and their critical effect on the prevention of type 2 diabetes. We all agree that the best way to prevent complications of diabetes is to prevent the disease in the first place. The Diabetes Prevention Program (DPP) and other studies done in Europe and China have shown that type 2 diabetes can be prevented in about 50% of people that are highly likely to get type 2 diabetes. These people prevented type 2 diabetes through a healthy meal plan and moderate physical activity that resulted in moderate weight loss. I suggest to my patients that they
RISK FACTOR
TARGETS
Blood sugar
Close to normal without causing low blood sugar; individualized
Blood pressure
Less than 130/80 mm Hg
LDL (“bad”) cholesterol
Less than 100 mg/dL Less than 70 mg/dL (if have history of cardiovascular disease)
HDL (“good”) cholesterol
Greater than 40 mg/dL (men) Greater than 50 mg/dL (women)
Triglycerides (fat)
Less than 150 mg/dL
should include physical activity as a part of their daily life, and not just as an add-on. There should be a time of the day that is devoted solely to your personal health and well-being. The positive effects of a healthy diet, weight loss, and exercise can add to each other. You can lose weight by working with your health-care team and having a meal plan that contains adequate amounts of fiber, fruits, and vegetables, and has the appropriate amount of calories. Losing weight and keeping it off it is not easy and requires a lifestyle change in both attitude and behavior. As the author Thomas Paine once said, “The harder the conflict, the more glorious the triumph.”
“WHAT ABOUT MEDICATIONS, AND HOW CAN I PREVENT THE COMPLICATIONS OF TYPE 2 DIABETES?” Again, you need to talk to your health-care provider about this. Here our goals and targets for sugar control are more complex, because type 2 diabetes is different in different people. Your goals may depend on many factors, such as your age, how long you have had diabetes, and your overall health. It is important to know that managing diabetes is more than just controlling blood sugar. Controlling blood pressure and cholesterol levels Continued on page 4 Dr. Faramarz Ismail-Beigi is a professor of Medicine, Endocrinology, and Physiology and Biophysics at Case Western Reserve University, University Hospitals of Cleveland, and the Cleveland VA hospital. He received his doctoral degree and post-graduate training at Johns Hopkins School of Medicine in Baltimore. He also serves as the Medical Director of Joslin Diabetes Clinic at St. Vincent Charity Hospital in Cleveland. He conducts basic and clinical research in diabetes.
POWER OF PREVENTION • VOL. 2, ISSUE 2
3
Continued from page 3
are also very important. You may have to take a daily aspirin, and stopping smoking is a must. An important study named Steno-2 showed that doing all of the above at the same time can reduce heart attacks and death by close to 50%. So, each one of these factors plays an important role in the development of large vessel disease. Aim to get your blood sugar values close to normal especially if you are young or middle-aged and your diabetes is new. This recommendation is based on results of a large study conducted in England (the UKPDS trial) in patients who were recently discovered to have type 2 diabetes. The study showed that good control of blood sugar and blood pressure reduces the risk of damage to both small and large blood vessels and their complications. We try to reach this goal while avoiding frequent episodes of low blood sugar. Three very large studies related to this topic have been carried out with the help of more than 22,500 participants with type 2 diabetes (the ACCORD, ADVANCE, and the VA Diabetes Trial). The results suggest that in people who have had type 2 diabetes for many years, trying to get their sugar levels very close to normal (or normal) does not always reduce the risk of complications associated with large vessel disease. However, they did show benefits in preventing small blood vessel complications. This is why the goal for blood sugar control is not the same for every person and must be tailored to each patient. To reduce the risk of large vessel disease in type 2 diabetes, we should always pay attention to blood pressure, blood cholesterol, and fat control. I have listed the targets recommended for most patients with type 2 diabetes in the box. Remember that getting to these goals at the same time makes a very large difference in preventing complications. The great news is that diabetes complications can be prevented. Today we have many new therapies, tools, and technologies to treat diabetes to prevent complications. The first step is to know your goals. Staying informed and engaged in your own care, and working closely with your health-care team will ensure that you will remain healthy! P
LOOKING FOR A HEALTHY HEART? IT’S MORE THAN JUST BLOOD SUGAR!
Heart disease is the number one cause of death in the United States. And people with type 2 diabetes are at much higher risk for heart disease. You may ask, why? People with diabetes often have higher blood pressure and cholesterol, and higher risk for blood clots. These conditions increase the risk for heart disease, stroke, and circulation problems in the legs. Several studies have shown that people who have diabetes and have not had any sign of heart disease still have the same risk or higher risk of a heart attack than people who have already had a heart attack over the course of five years. What can you do to protect your heart? HERE IS THE 10-STEP PROGRAM FOR A HEALTHY HEART 1 Eat a heart-healthy diet.
Reduce total calorie intake with less simple carbohydrates (sugars) Eat less saturated fat
Increase vegetable and fiber intake Reduce salt intake
2 Stay active.
Moderate physical activity such as walking 30 minutes a day five times a week goes a long way!
Lose weight. 3
Just 5% to 10% of body weight lost can make a difference!
4 Get your cholesterol and blood fat to goal.
Reduce your LDL (bad cholesterol) to below 100 mg/dL, even below 70 mg/dL Increase your HDL (good/protective cholesterol) to above 40 mg/dL for men and above 50 mg/dL for women Reduce your triglycerides (blood fat) to less than 150 mg/dL
Take your prescribed medications. Statins, drugs like lovastatin, simvastatin, atorvastatin, rosuvastatin are often needed. They have been shown to reduce one’s risk for heart disease and stroke, and even death in people with and without diabetes
5 Control your blood pressure. It should be lower than 130/80 mm Hg 6 Control blood sugars. 7 Stop smoking. 8 Take a daily aspirin.
Aspirin or blood-thinning medication may be needed to prevent a repeat heart attack or stroke
9 Reduce stress, relax, and smile often. 10 Keep in contact with friends and family – Connections are important!
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POWER OF PREVENTION • VOL. 2, ISSUE 2
ON PENS
AND NEEDLES:
What You Need to Know About Injectable Diabetes Medications B Y E T I E S . M O G H I S S I , M D , F A C P, F A C E Have you been told that you need to start an injectable diabetes medication? Are you afraid to even think about it? Are you thinking that injections are painful, inconvenient, and those needles are really scary? Plus, what might others think if they see you inject? Are you worried about what it means to need insulin injections? Do you know people who started insulin and ended up with other problems? This is all understandable, and you are not alone. The truth is that there is a lot of confusion and misunderstanding about injectable medications, such as insulin or other kinds of medication.
WHY INSULIN? Many people with diabetes believe that insulin therapy means that their condition is worsening or they consider it as a personal failure. They are afraid of low blood sugar and weight gain, or that their injection may be painful. It is important to know that one of the main problems of diabetes is that the pancreas does not produce enough insulin. Insulin is the natural hormone that is needed to keep blood sugar under control, and only insulin can replace insulin! So you may ask, “Who needs insulin?” All persons with type 1 diabetes need insulin to survive, and many people with type 2 diabetes eventually need insulin to control their blood sugar. And, many pregnant women with diabetes, or who have diabetes during pregnancy, need to be on insulin for a healthy baby. The bottom line is that insulin can be lifesaving for many people with diabetes. Yes, insulin therapy can be associated with low blood sugar and weight gain if you are not careful with your meal plan and your physical activity. Newer insulins have a lower rate of hypoglycemia [hy-po-gly-SEEM-eeah] (low blood sugar) than older insulins. Also, newer insulin delivery devices (such as insulin pens) are more convenient than the traditional insulin vial and syringes. If you have been told that you need to start insulin, or if you are already taking insulin, you should know about the insulin pens. They give accurate doses, are very convenient (can be carried around in your pocket or purse), and are covered by many insurances and prescription plans. The pen needles are so thin and so small that they are almost pain free. To get over being scared of needles and injections, you should give your first insulin injection into the skin of your abdomen (belly)
or thigh while you are in your health care provider’s office. You will see for yourself that the pain of the injection is nowhere close to the pain of finger sticks that you do all the time to test your blood sugar. The reason for less pain is that there are far less pain fibers in the skin of your abdomen and thighs than there are in your finger tips. So, there is no need to live in fear. Experience the first injection in the safety of your health care team’s presence. To avoid experiencing low blood sugar, learn to prevent it in the first place. You should monitor your blood sugar and you should not skip meals. Know what to do with the amount and the timing of your insulin injections relative to your physical activity.
THE NEW INJECTABLE DIABETES MEDICATIONS THAT ARE NOT INSULIN There is a new class of diabetes medications (called incretins [inKREE-tins] or gut hormone-like) that need to be injected but are not insulin. These medications stimulate your own body to make insulin to keep your blood sugar under control. The good news about this new class of medication is that they almost never cause low blood sugar (hypoglycemia) by themselves. The better news is that they actually can lead to weight loss instead of weight gain. They are easier to use because they are all administered by pen injectors, which are almost pain free, and can be carried around. Currently, there are 2 types of these medications available, exenetide [ex-EN-ah-tide] (Byetta) and liraglutide [lir-AHgloo-tide] (Victoza). And, more are on the way. Another injectable medication for diabetes is pramlintide [PRAM-lintide] (Symlin) which is used with insulin to control post-meal blood sugar and is also taken with a pen injector. In summary, only you and your health care team can decide which medication is right for you. Remember that these are tools to help you get you to your blood sugar goals. You should focus on your goal (optimal blood sugar control). The goal is the most important. How to get there may be less important. Work with your health care team to find the right option for you. For some people, the best option may be pills. For others, the best option might be an injection. Do not let fear or false ideas prevent you from reaching your destination! (Your good health!) P Dr. Etie Moghissi is board certified in endocrinology, diabetes and metabolism and is in private practice in Marina del Rey, California. She is a Clinical Associate Professor of Medicine at UCLA. Dr. Moghissi is a recognized expert in the field of diabetes and is actively involved in direct patient care, as well as in professional medical education. She has published in peer-reviewed medical journals including Endocrine Practice and Diabetes Care. She serves as Treasurer of the American Association of Clinical Endocrinologists, and is Secretary/Treasurer of the American College of Endocrinology.
POWER OF PREVENTION • VOL. 2, ISSUE 2
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INCRETINS: NEW TREATMENTS f o r Ty p e 2 D i a b e t e s This piece has been adapted from an article written by Alan J. Garber, MD, PhD, FACE. Incretin [in-KREE-tin] hormones are a new type of treatment for managing people with type 2 diabetes. Incretin hormones raise insulin after meals, which then lower blood sugar. Incretins also decrease a hormone called glucagon [GLOOkah-gon], which then raises blood sugar. Incretin hormones play a very important role in keeping the blood sugar in the normal range in people without diabetes. In people with type 2 diabetes, incretin hormones are reduced, and they also slowly lose their ability to make insulin over the years. This is the reason that patients with type 2 diabetes will need insulin someday to control their blood sugar. Incretin hormones show a lot of promise for long-term benefit. This is because these drugs might slow down insulin loss. And, unlike some older blood sugar medications, incretin hormones have fewer side effects. For example, drugs such as glyburide [GLIGH-bureride], glipizide [GLIP-ih-zide], or glimepiride [gly-MEP-ih-ride] that increase blood insulin can cause weight gain and low blood sugar. GLP-1 is one of the incretin hormones. GLP-1 slows down the emptying of food from the stomach. So, food stays in the stomach longer and this makes people feel full. It also works on the brain to decrease appetite. With less food eaten, it can help people lose weight. But, GLP-1 is destroyed very quickly in the body by an enzyme called DPP-4. In fact, over half of GLP-1 is gone in two minutes! Because of this, GLP-1 itself cannot be used for treatment. There are two main ways of getting normal incretin hormone action. The first way is to use agents that are very similar to GLP-1, but are not destroyed so rapidly. These drugs come as injections. Exenatide [ex-EN-ah-tide] (Byetta) is one of these drugs and is injected twice daily. Recently, a new human GLP-1 look-alike drug, also injected, has been approved for patients with type 2 diabetes. This new drug called liraglutide [lir-AH-gloo-tide] (Victoza) is injected once a day. These two agents do not cause very low blood sugars unless the person is also taking other drugs that can cause low blood sugar. Liraglutide can be taken any time during the day, but exenetide should be taken before meals. People taking liraglutide lost almost twice as much weight and lowered their blood sugar almost twice as much compared to people taking glimepiride. Liraglutide should not be used in patients with a certain thyroid cancer called medullary [MED-yoo-lerry] cancer of the thyroid or in people with a family history of this kind of cancer. Inflammation of the pancreas (called pancreatitis [pan-kree-ahTITE-iss]) has been seen in patients treated with either exenetide or
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POWER OF PREVENTION • VOL. 2, ISSUE 2
Dr. Alan Garber graduated from Temple University, Philadelphia, in 1968, completed a PhD in Biochemistry in 1971, and a residency in Internal Medicine. Subsequently, he was a fellow in Metabolism and then a junior faculty member at Washington University Medical School and Barnes Hospital in St. Louis. In 1974, he transferred to Baylor College of Medicine in Houston, where he is presently a Professor in the Departments of Medicine, Biochemistry and Molecular Biology, and Molecular and Cellular Biology. Dr. Garber currently serves as Secretary of AACE.
liraglutide, although this side-effect has not been proven. The main side effect of both of these drugs is feeling sick to the stomach and throwing up, which usually go away after a few weeks. The second way to increase blood incretin hormone action is to block the fast destruction of GLP-1. This can be done by blocking the DPP4 enzyme. Sitagliptin [sit-ah-GLIP-tin] (Januvia) and saxagliptin [SAX-ah-GLIP-tin] (Onglyza) are two medications that can be taken by mouth. They do not cause low blood sugar, and they work well with other diabetes drugs, such as metformin. However, unlike exenetide and liraglutide, they do not cause loss of appetite or weight loss. You need to discuss with your health-care team whether you are a good candidate for these new agents. They can help you use them well and safely. The weight loss seen with the injected incretins can be a major benefit to many people with diabetes. P
NEW TOOLS IN THE SHED: INSULIN, CONTINUOUS GLUCOSE MONITORING, INSULIN PUMPS, AND GLUCOSE METERS B Y E R I C A . O R Z E C K , M D , F A C P, F A C E , C D E Several new products could help you manage your diabetes. Living with diabetes is easier than it used to be. This is because of changes in glucose meters and test strips, new ways to administer insulin (pumps, disposable pens, and ports), and advances in continuous glucose monitoring. This year Bayer came out with the Contour USB meter. It the first glucose meter that plugs directly into your computer. It is about the size of a USB storage device, plus it has a color screen for easier viewing of data. And instead of confusing error codes, messages tell you the exact reason for errors. The meter is available at many pharmacies or web sites for around $80. Using new technology, WaveSense recently released their Presto and Jazz meters (also sold as the Kroger meter at Kroger pharmacies). Because these meters’ test strips do not use platinum and gold as do current strips, they can be sold at a lower price. A vial of 50 strips sells for $16 to $22, which is currently the lowest cost per strip on the market. The meter does not require strip coding. It has on-screen graphs, supports alternate site testing, and uses a small sample size. There is also an iPhone App available for download to an iPhone or iPod Touch. Another big change is in continuous glucose monitoring (CGM), which allows you and your doctor to have more information about your glucose (sugar) levels. Abbott, DexCom, and Medtronic have CGM devices that your doctor uses. “Personal CGM” refers to devices that give readings in real time. Each system can be programmed to sound an alarm if high and low glucose limits are breached. Some systems will also alert the wearer of how fast their glucose levels are changing. Recent developments have made taking insulin more convenient than ever. The OmniPod insulin pump has a wireless, tube-free pump that attaches directly to the abdomen. They also have a new Personal Diabetes Manager, which controls all of the boluses (drug administrations) and settings. This device is simpler to use and easier to read (color screen) than the older model. The software has been updated to work with the Copilot Software that Freestyle blood glucose meters use. The Animas One Touch Ping insulin pump, which came out in late 2008, also has a color screen for easy reading. Other updates to the Animas pump include a food database and wireless bolusing from the included One Touch meter that make the pump more discreet. Also, Medtronic, Animas, and Accu-chek have new infusion sets that offer more options.
Another advance is Novo Nordisk’s Novolog which has been approved for use for six days in a pump reservoir. Other insulins are only approved for three days. You still need to change your infusion set every two to three days, or as directed by your doctor, but you can now leave your reservoir in place for six days if it is filled with Novolog. Another method of getting your insulin is to use the i-port. The i-port now comes with an inserter along with the unit. The i-port is an injection port that stays in place for three days. You can inject insulin into the i-port. Once inserted, you pull out a needle, which leaves a small plastic cannula under the skin. For the next three days all insulin is injected into the port. This avoids multiple through the skin injections, since there is only 1 needle stick for the three days. Different insulins can be used. The new i-port inserter works like those that are used for inserting infusion sets for insulin pumps using a spring-loaded device. These recent advances lead to more fun and convenience when it comes to diabetes management. More importantly, they allow you to have better control of your diabetes, prevent complications, and lead a life far less troubled by controlling your diabetes. P
Dr. Eric Orzeck is in the private practice of endocrinology in Houston, Texas. He is a fellow of the American College of Endocrinology and a fellow of the American College of Physicians. Dr. Orzeck has been a certified diabetes educator since 1989 and has served on the Board of Directors of The National Certification Board for Diabetes Educators. He is currently on the Board of Directors of AACE and is vice-chair of both the Socioeconomics & Member Advocacy Committee and the Pediatric Endocrinology Committee.
All trade names are the property of their owners and are used here solely for purposes of identification. POWER OF PREVENTION • VOL. 2, ISSUE 2
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Endocrinologist:
Health Literacy
THE SPECIALIST IN THE
HOW TO GET THE MOST FOR YOUR DIABETES CARE
COMPREHENSIVE CARE OF DIABETES BY YEHUDA HANDELSMAN, MD, FACP, FACE An endocrinologist [en-doh-cri-NA-lo-jist] is a doctor who is an expert in diagnosing and treating hormone and metabolism disorders. An endocrinologist is also an educator to the medical community and a resource to the public in general. Endocrinologists recognize and manage medical conditions associated with the thyroid gland, pituitary gland, sex hormones, growth hormone, bone health, lipid disorders, and other hormone conditions. Because there are so many people with obesity and diabetes, there is a huge demand for endocrinologists, who are experts in preventing and managing obesity, diabetes, and the potential complications of heart disease, stroke, and kidney disease. Even today people view diabetes as a simple issue of a “little” too much glucose (sugar) or “a touch of sugar.” Diabetes should be viewed as a complex medical condition that may affect every part of the body. For example, diabetes is considered as similar to heart disease from not just elevated blood sugar (hyperglycemia [hieper-gly-SEEM-ee-ah]), but also by the added problems of blood pressure, cholesterol, and increased risk of blood clots. There are at least 11 classes of medication for treatment of high blood sugars. There are also many drugs to treat blood pressure and lipid (cholesterol) problems. It takes a trained expert to know which treatments should be recommended and how best to put these treatments together for the best results for a specific person. Of course, the best treatment of diabetes is prevention. An endocrinologist is an expert in how to help you modify your lifestyle. An endocrinologist can help you with understanding nutrition and meal choices. The endocrinologist typically directs a team who helps you to increase your physical activity and who educate you in how to manage your health. Managing obesity to reduce heart disease risk can be challenging! Obesity, diabetes, high blood pressure, cholesterol problems, and heart disease affect nearly 150 million people in the United States. The endocrinologist is a leader in education to both the medical and patient communities. He or she teaches others how to manage complex treatment programs. The endocrinologist develops, trains, and leads teams of professionals. The team can include primary care physicians, physician assistants, nurse practitioners, nutritionists, diabetes educators, pharmacists, and fitness experts. Continued on page 26 Dr. Yehuda Handelsman is an endocrinologist practicing in Tarzana, California, and Medical Director and Principal Investigator for the Metabolic Institute of America. Dr. Handelsman serves as Vice President of AACE and Chair of the AACE Diabetes Council. He has assisted in developing various Association guidelines, position statements and the 2009 AACE Diabetes Algorithm. Dr. Handelsman is Chair and Program Director of the World Congress on Insulin Resistance, Diabetes and Cardiovascular Disease. He serves as Associate Editor of the Journal of Diabetes and is an authority on management of prediabetes, diabetes and prevention of cardiovascular disease.
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B Y S A N D R A L. W E B E R, M D, FAC P, FAC E Have you ever left your doctor’s office a little confused about what was said? If you don’t understand what is going on it is hard for you to have an active role in your treatment. It is important for you to understand your diabetes and what your doctor has advised you to do. Why is this important? To improve your health! The relationship between health literacy and good health has been shown in many different settings including diabetes care. WHAT IS HEALTH LITERACY? It is the ability to understand and act on medical and therapeutic instructions. Have you received a prescription, been told how to take your insulin over the phone, read an article in a paper, shown up for a screening? You are likely to have understood part, most, none or all, depending on how clear the instructions were and your knowledge about what was said. More than one in 3 adults in the United States is felt to have low health literacy. Let’s lower that number! DOCTOR, WHAT DID YOU SAY? Take your insulin twice a day. What does that mean? a. AM and PM b. Waking and bedtime c. Before breakfast and before supper d. 6 AM (set your alarm!) and 6 PM, exactly 12 hours apart I am not sure. I’D BETTER ASK!
Take your medicine with your meal. What does that mean? a. 15 minutes BEFORE you eat b. AFTER you eat c. As you are taking your first bite d. What if I don’t eat? I am not sure. I’D BETTER ASK!
If you are sick, increase your insulin. What does that mean? a. My basal insulin b. My meal insulin c. My correction insulin d. All insulin doses e. By how much? I am not sure. I’D BETTER ASK!
HOW CAN I IMPROVE MY HEALTH LITERACY? Learn as much about diabetes as you can! Know what is important in your diabetes care. Prepare for your doctor visit. Think about the issues that have come up since your last appointment with your doctor. Write down your questions. It is easy to forget your own very important questions in the context of a face-to-face meeting and in the course of a clinic visit where many things can happen that demand your undivided attention. And if an instruction is not clear, ask to have it explained again or in a different way. Write instructions down or have them written so you have something to reference later. It is hard to remember all instructions, whether simple or complex instructions. Information may be new and or many changes or additions might be recommended. If you cannot read, get instructions verbally and say them back to confirm that you both have the same plan. If your treatment plan is changed by your doctor, changed from your plan, review why. There is usually a good reason, and discussing it is the key. Were there side effects? Was it hard to get the medication? Did it cost too much? Did your pill look different? Continued on page 26 Dr. Sandra Weber is Clinical Professor of Medicine at Greenville Hospital System University Medical Center. She serves as chief of the section of endocrinology and chair of continuing medical education. She is active in clinical practice, teaching and research, and loves the opportunity to care for people with diabetes.
What Is an A1C Test?
BY ZACHARY T. BLOOMGARDEN, MD, FACE
S E E M S L I K E M Y D O C T O R I S A LW AY S O R D E R I N G I T When a person with diabetes sees an endocrinologist [en-dohcri-NA-lo-jist], they soon learn about a test called hemoglobin A1C, or HbA1c, or, simply, A1c. The A1C, they are told, should be as low as possible (the American Association of Clinical Endocrinologists [AACE] recommends a level of 6.5% or less). A person with diabetes may also learn that an A1C of 6.5% is a benchmark for diagnosing diabetes. What is A1C? Is it truly useful? What does it mean as a benchmark of diabetes control? A1C represents the attachment of glucose (sugar) to hemoglobin (the oxygen-carrying protein in our red blood cells). The red blood cells need glucose for their metabolism. When the hemoglobin in the red blood cell meets glucose, glucose slowly (over days and weeks) attaches to an amino acid on the hemoglobin. At this time, a person’s A1C level would show the amount of glucose that the red blood cells have been exposed to over time. Since the average life of a red blood cell is 3 to 4 months, the A1C shows an average blood sugar level, not just at the time the blood test was done, but during the long period leading up to that time. Normally, when a person does not have diabetes, their blood sugar is below 100 mg/dL before meals, and it rarely rises over 120-130 mg/ dL after meals. In these circumstances, the A1C is around 5%. This means that 5% of the hemoglobin molecules in that person’s millions of red blood cells have glucose attached. In mild diabetes (with a fasting blood glucose just over 125 mg/dL or the blood sugar 2 hours after an oral glucose tolerance test around 200 mg/dL), the A1C will be over 6%. So, 6% of their hemoglobin molecules have glucose attached. At 7%, 8%, and 10% the blood glucose levels during the day become higher, and so, blood sugar levels in the morning before eating might be around 150 with an A1C of 7%, then 180 with an A1C of 8%, and then 240 mg/dL with an A1C of 10%. But this leads to an important issue. Not all people have red blood cells that live for the same amount of time. Men’s red blood cells live for about 117 days, and women’s red blood cells live for about 106 days. If one person’s red blood cells live for 4 months, and another person’s red blood cells live for 2 months, the A1C could be only half as great in the second person. It’s not quite that bad usually, but anemia, low red blood cell levels, certain genetic issues, and many illnesses, such as chronic infections and chronic kidney disease, lead to a lower blood A1C level. African American people tend to have higher A1C levels than white people, and young people have lower A1C levels than older people. Everyone’s body is different, so if we very carefully measure a person’s blood sugar many times a day for many days some people have a higher A1C and some have a lower
A1C. Another factor in the different A1C levels is that lab tests are not perfect. Doctors expect a small range in values in most blood tests. For example, for an A1C blood test result of 6.5%, the person’s actual level could be anywhere between 6.3% and 6.7%.
A1C is a very useful indicator of the average blood sugar level for a person with diabetes. A1C is, then, a very useful indicator of the average blood sugar level for a person with diabetes. It also may determine that a person is at risk of having diabetes. However, doctors look at it along with information about the average blood sugar levels for that specific person. This is why most endocrinologists advise that people with diabetes measure their own blood sugar levels at home regularly, at various times of the day. This gives the patient and the doctor a better sense of the control (or lack of control) of the person’s diabetes. The A1C test then helps to provide a full picture of how well the diabetes is controlled. The American Association of Clinical Endocrinologists (AACE) has recommended that though it makes sense to use A1C to diagnose diabetes, the test can be misleading. So, if a doctor finds that a patient’s A1C level is 6.5%, AACE terms it diagnostic of diabetes. AACE does recommend confirming this with the blood sugar reading “when feasible,” although my opinion is that blood sugar measurements should always be done. Certainly, if the patient’s diabetes status is not clear, the patient should have an oral glucose tolerance test. If the fasting glucose is 126 mg/dL or more or the 2-hour glucose is 200 mg/dL or more, then diabetes is confirmed. This approach, patients checking their own blood sugar (for diagnosed diabetes) and careful glucose testing (to diagnose diabetes), allows us to determine the diabetes condition of each person. P Dr. Zachary Bloomgarden has a national reputation for writing and lecturing on diabetes. He is Clinical Professor in the Department of Medicine and is active in the Division of Endocrinology & Metabolism of the Mount Sinai Medical Center, New York, New York. He runs a major teaching activity; the weekly diabetes clinic conferences with the participation of speakers from the institution and numerous invited guests; and participates in teaching rounds in the Departments of Geriatrics and Pediatrics, as well as Medicine.
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WINDOW of Opportunity
TECHNOLOGY TO HELP YOU STAY ON TRACK WITH
BY SARAH SENN
DIABETES: A P P S ,
W E B
S I T E S ,
Nothing could stop Sharon Beam from enjoying life. From her budding career to her passion for hiking, Sharon was at the top of her game. But at 34, Sharon’s life changed. She was diagnosed with type 1 diabetes.
A N D
I N T E R N E T
R E S O U R C E S
BY VICTOR LAWRENCE ROBERTS, MD, MBA, FACP, FACE
P
eople who manage their diabetes are faced with many challenges. They have to deal with food restrictions, exercise goals, medications to take, and work and family responsibilities. They also have to deal with doctor visits and frequent lab tests, and, of course, measure their blood sugar (glucose). As health care professionals, we encourage and teach our patients to partner with us to actively interpret the personal data collected on a daily basis and respond accordingly. Now that internet technology is available to most of us, there are more powerful ways to stay informed about diabetes and find new ways to stay on track. In this section, we will talk about a few of the many options you may choose to make the task of home blood sugar monitoring more efficient and effective. Some of these tools can also help you to increase your understanding about the risk of diabetes complications and alert you to reduce your risk.
APPLICATIONS (APPS) GoMeals™, a new iPhone application (app) designed by sanofi-aventis, is designed to help people living with diabetes make healthy food choices. You can download it at the iTunes App store. This is a food-tracking device. It enables you to search thousands of foods and dishes from popular restaurants and grocery stores. Nutritional content of the meals and snacks is displayed. GoMeals™ can be used by anyone who wishes to monitor the nutritional content of their meals, though it was designed for patients with diabetes. I downloaded GoMeals™ to examine the features. With “Today’s Plate,” you can monitor your daily calorie intake, along with the amount of carbohydrates (carbs), proteins, and fats. The data is shown in a pie chart. The nutritional information comes from the CalorieKing™database, which contains more than 200 restaurant menus and over 25,000 common food items. A restaurant locator is included and offers a nice resource for people on the go. This app is free. From the HealthCentral.com Web site, I found this list and some of the commentary (abridged): • Glucose Buddy, developed by OneAppOneCause URL: http://www.oneapponecause.com Price: $5.99 (currently offered for free) The application lets you enter and analyze statistics for blood sugar, medicine, and food values. You can also enter activity values. Data graphing and e-mailing of the information is available.
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• Diabetes Log, developed by Chris Ross URL: http://www.distal.com/diabeteslog/index.html Price: Free This App offers multiple languages besides English: Dutch, French, German, Russian, Spanish, and Swedish. • Islet 2.0, developed by iAbetics URL: http://www.iabetics.com Price: $2.99 (currently on sale for $0.99) Islet 2.0 lets you enter glucose, insulin, food, and exercise data. It offers graphs with high, average, and low values on an hourly, daily, weekly, or monthly intervals. • Glucose-Charter, developed by Dr. Lee Konowe URL: http://glucose-charter.com Price: $0.99 Blood sugar recording is complemented with a food database to assist in dietary selections. • Diamedic, developed by Martoon URL: http://www.martoon.com/diamedic/ Reviews: 30 Price: $5.99 Diamedic Diabetes Logbook lets you record every blood sugar reading and insulin injection.
INTERNET RESOURCES AND WEB SITES In addition to the Power of Prevention Web site (www.powerofprevention.com), there are many helpful educational resources on the Web that can help you to stay informed and manage your diabetes. Some of these are as follows: • http://www.calorieking.com/ This site was developed for those looking for a weight-loss tool. However, it can also be used not only to look at total calorie content of foods, but also to look at carbohydrate content, fat content, and salt (sodium) content. It even has brand-name product contents as well many restaurant meal contents. It is free, although it is also available for downloading to a PDA for a fee. Continued on page 26 Dr. Victor Roberts is a partner with Endocrine Associates of Florida, P.A., in Winter Park, Florida. Dr. Roberts is a Professor of Internal Medicine at the University of Central Florida; Clinical Professor of Medicine, University of Florida; and Clinical Professor of Clinical Sciences, Florida State University. He is also a Certified Diabetes Educator (CDE) and Medical Director of Endocrine Clinical Research. Dr. Roberts is a volunteer member of the Central Florida Medical Reserve Corps for disaster relief and is a member of The Best Doctors in America and Top Doctors.
For Sharon, the active lifestyle of Santa Monica, California, is exciting. Before her diagnosis, Sharon was a true career woman. She worked for an education company coordinating inner-city education programs nationwide. Although the job was often stressful, she enjoyed the dayto-day challenges and traveling for her job. Sharon has always been driven and was searching for other ways to expand her career. With a background in holistic health, Sharon was excited to be given an opportunity to open a wellness center with a local physician. The strain of juggling the two jobs sent Sharon’s immune system over the edge. During a business trip in May 2009, Sharon noticed something different. On the first day of the trip, her vision was blurry and by the end of the trip, she could not see well enough to drive. When she got home, Sharon’s mother, who has type 2 diabetes, suggested that Sharon test her blood sugar level. Her blood sugar level was more than 320 mg/dL. Sharon made an appointment with the doctor right away. Blood tests showed that Sharon’s pancreas was not functioning properly. She had type 1 diabetes.
Diabetes opened a window for me. “At 5 ft 8 ½ in and 120 lbs, I thought I was healthy. I was eating right and staying fit. I didn’t know I could get type 1 diabetes,” she said. Sharon’s diagnosis was heartbreaking to her at first. She went from diagnosis to denial. Sharon thought she was doing everything right. She went to yoga classes weekly and ate nearly a vegetarian diet. When she wasn’t working, Sharon was hiking, her favorite pastime. At age 34, Sharon and her husband, Lou, were thinking about starting a family, but when she was diagnosed with diabetes, she was unsure if this would be possible. “Emotionally, I felt like I was damaged goods,” she said. About a month after being diagnosed, while on a typical hiking venture in Sequoia National Park, Sharon met a group of hikers from Stanford who told her about a study related to diabetes and stem cell research. Sharon has always been passionate about research and understanding her health. She contacted Stanford about enrolling in the study. However, if she was accepted as a study participant, Sharon would have to put the plans for having a family on hold for at least two
years. Although it was a tough decision, and uncertain of whether they would still be able to have children in a few years, Sharon and her husband, Lou, decided it was best for her health to participate in the study. She went through various levels of study screenings, but during the final screening she was removed from the study because she had something wrong with her lungs, but it was unrelated to diabetes. Another setback— Sharon was devastated, but now she was even more determined not to let diabetes slow her down. “You have to take responsibility for what happens to you,” she explains. In just over two months after being diagnosed, her blood sugar levels were under control and her A1c level had fallen to 5.7. Sharon decided to focus on her health and managing her condition. Inspired by her diabetes, she stopped working full time and decided to become certified as a yoga instructor. She now teaches yoga every morning and she hikes three times a week. Sharon has been working with her endocrinologist [en-doh-cri-NA-lo-jist] to determine the treatment that is best for her. At first, Sharon managed her condition through individual insulin injections multiple times daily. But with an active lifestyle, she found an insulin pump works best. Admittedly, Sharon was concerned about using an insulin pump to control her condition. “At first I thought that the pump would be like being on life support, but now it has become second nature,” she said. “It’s helped me find my new normal.” She has turned to others who have type 1 diabetes for advice on nutrition and management techniques. Sharon has also found new hope for an old dream. Shortly after learning that she would not be able to take part in the Stanford study, she found out about a study with the Sansum Diabetes Clinic for women with diabetes who are trying to conceive. Sharon qualified as a study participant, and she is looking forward to starting a family within the next year. While she calls her journey over the last year an “emotional rollercoaster,” Sharon finds comfort in what she’s learned about herself. “I can’t say that I’m glad I was diagnosed; I roll with the punches,” she admits. “But if I have to find the silver lining, it’s the realization of how precious our lives are. Diabetes opened a window for me.” P POWER OF PREVENTION • VOL. 2, ISSUE 2
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Planning for Your Healthy Baby: Pregnancy and Diabetes BY RACHEL PESSAH POLLACK, MD Do you have diabetes? Are you thinking about getting pregnant? If so, there are things you need to do for the health of you and your baby during pregnancy. Your blood sugar control is very important.
• High blood pressure – your doctor will want to make sure that your blood pressure is under good control before you get pregnant. You may have to switch or add blood pressure medications.
DIABETES DURING PREGNANCY IS ON THE RISE
• Nerve disease – your doctor may suggest you see a foot specialist (podiatrist [poe-DYE-ah-trist]) to determine if you have diabetic nerve disease. This is also known as peripheral neuropathy [per IH-fer-al noor-AH-puh-thee]. It is important to take good care of your feet before and during pregnancy and to check your feet each day to keep infections at bay.
More and more people are getting diabetes. There are about 1.5 million new cases per year. As a result, many more women with type 2 diabetes are becoming pregnant. Elevated blood sugar (glucose) levels during pregnancy are bad. They can cause a higher risk of birth defects, miscarriage, birth injury, preterm delivery and certain complications such as pre-eclampsia. By being careful with blood sugar levels before becoming pregnant and during the early weeks of pregnancy, these potential problems can be prevented. Here is what you can do to optimize your care and ensure a successful outcome:
SCHEDULE YOUR DOCTORS’ VISITS *Your doctor may send you to a specialist before you get pregnant to help you with your diabetes control. *Obstetrical [ob-steh-trih-kal] care – some patients with diabetes may see obstetricians [ob-steh-TRIH-shen] who specialize in high-risk pregnancies. Your doctor will help you make this decision based on how long you have had diabetes and how well your diabetes is controlled. • Eye disease – every woman with diabetes should see an eye doctor for an eye examination before getting pregnant. You may be counseled on the risk of getting diabetic eye disease (retinopathy [reh-tin-AH-pah-thee]). Eye exams are also recommended in the first trimester, during pregnancy, and after birth. Sometimes the eye disease may become worse with pregnancy; however, this risk can be prevented with laser surgery. • Kidney disease – all women with diabetes who want to get pregnant should be checked for diabetic kidney disease (nephropathy [neh FRA-pah-thee]). A urine test is used for this test. Dr. Rachel Pessah Pollack is a second year endocrine fellow at Mount Sinai Medical Center in New York City, where she also received her internal medicine training. She is the AACE Fellow-in-Training Representative and has a special interest in pregnancy-related endocrine disorders. She has published articles and given presentations on gestational diabetes, Cushing’s disease during pregnancy, and iodine deficiency during pregnancy. This fall she will be joining a private endocrinology practice in New York.
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FOCUS ON HEALTHY EATING NOW Before pregnancy, it is a good time to pay close attention to what you eat. Eating properly is important to achieve and maintain normal sugar levels throughout pregnancy. You are hopefully already following a healthy diabetes diet, including fruits, vegetables, and fiber. You can continue to eat the same foods as you plan for pregnancy. However, be aware that, during pregnancy, how many carbohydrates there are in each meal is the most important factor affecting your blood sugar control, both before and after your meals. It may be useful to meet with a registered dietician or diabetes educator before you get pregnant. This will help you learn how to count calories and choose healthy foods. In addition to watching your diet, all women who want to become pregnant should take a daily prenatal multivitamin containing at least 400 micrograms of folic acid. Folic acid prevents neural tube defects, such as spina bifida [spine-a BIH-fid-a] in babies.
TARGET NORMAL BLOOD SUGAR LEVELS Studies have shown that poor blood sugar control during pregnancy can lead to poor pregnancy outcomes and risk for birth defects. During the first trimester, the baby’s organs are forming and normal sugar levels can decrease the risk of any problems during this period. For this reason, it is very important to wait to conceive until blood sugars are under excellent control. Hemoglobin A1C, which is a measurement of your blood glucose control over the prior two to three months, should be checked before you get pregnant to help with your overall diabetes treatment plan. Talk with your health care provider about what your blood sugar range and A1C level should be both before
pregnancy and during pregnancy to reach your goal of a normal blood sugar. Blood glucose self-monitoring is recommended by many different diabetes organizations (each has different target levels). During pregnancy you will be asked to check blood sugar levels one to two hours after the first bite of your meal. This is different from when you weren’t pregnant.
REVIEW YOUR MEDICATIONS FOR SAFETY Before you get pregnant, have your doctor review your medications and determine if you need to switch them to ones that are safe in pregnancy. Some examples are listed below:
Keeping fit will help with both weight loss and control of your blood sugar. Check your sugar level before and after exercising because you may need to eat a snack to prevent low blood sugar during physical activity. Continue your exercise routine during pregnancy unless your doctor advises against it.
AVOID BAD HABITS It is very important to get counseling from your doctor before you become pregnant so that you have a healthy pregnancy. Women with diabetes should be screened for depression, tobacco and alcohol use, drug abuse, weight management, and exercise.
• Diabetes medications - Many of the diabetes pills that are taken when not pregnant cannot be taken when pregnant. Before you get pregnant discuss with your doctor whether you may need to start insulin before or during pregnancy. Or, you might find out that diet and carbohydrate monitoring are all you need. In general, if insulin is needed, you will likely need to use more insulin the further you get into your pregnancy, especially during the third trimester. Although there is some good data with certain pills for diabetes, it is not known how safe and effective they are, and insulin is often recommended to control blood sugar.
• If you are a smoker or are still drinking alcohol, the perfect time to stop is before you get pregnant.
• Blood pressure medications: ACE inhibitors and ARBs used for blood pressure control and kidney disease are not advised during pregnancy, since they are likely to harm the baby. Before you get pregnant, consult your health care team about changing your blood pressure medications.
It is important for each woman with diabetes to know when a pregnancy is not safe. If your diabetes is not under good control, you should wait to become pregnant. By working with your health care team and making adjustments to your treatment, you can improve control of your blood sugar and ensure a healthy outcome for you and your baby.
• High-cholesterol medications: “Statins,” a class of medication used for its cholesterol-lowering effects, should be stopped before you get pregnant.
EVALUATE YOUR PRE-PREGNANCY WEIGHT
• If you are abusing drugs (prescription/non-prescription), now is the time to stop and get help if necessary. • If you have missed doses of insulin or if you don’t take your medications as prescribed, focus on taking the best care of your body as you prepare for pregnancy and avoid missing doses.
KNOW WHEN YOU NEED TO WAIT
There is a lot of planning to be done. However, you must remember that the patience and additional work is worth the end result: your healthy baby! P
Women with diabetes who are overweight or obese have a higher chance of having problems during pregnancy. These problems include higher rates of cesarean section, high blood pressure, birth defects, and premature infants. The good news is that if you are overweight and are able to reduce or normalize your body weight before you get pregnant, you can prevent many of these poor outcomes from occurring. Losing just a few pounds can help you maintain better control of your sugars and lower your blood pressure.
PLAN TO EXERCISE Once your doctor has decided that you are healthy for physical activity, add exercise to your daily regimen. Choose activities that you enjoy and are most likely to continue with and have a goal of 30 minutes of aerobic exercise most days of the week.
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How Much Should I Be Eating? Counting Calories for Weight Management
BY SARAH SENN
B Y E L I S E M . B R E T T, M D , F A C E , C N S P
How important is it to know your family history when it comes to your health? Just ask Jamila Akutu.
No one enjoys counting calories. Everyone wants an easy solution to weight management. That’s why diets such as Atkins™ and The South Beach Diet® are so popular. They don’t involve counting calories; you just have to follow the rules. These diets often work in the short-term because by banning certain foods total calorie intake for the day is reduced. But eventually, they most often fail either because they are difficult to stick to or because one manages to overeat the allowed foods. If you truly want to lose weight, it all boils down to calories in vs. calories out, no matter where the calories come from. So, what is a calorie? A calorie is a unit of energy. It is defined as the amount of energy required to raise the temperature of 1 kg of water 1 degree centigrade. How many calories does one need in a day to maintain weight? To lose weight? Several factors affect the amount of calories you burn in a day. To understand this, we must first define resting energy expenditure (REE). The REE is the amount of calories you would burn each day if you were to do nothing but rest. This is determined by factors such as your weight, height, age, and amount of lean body mass. The more you weigh, the taller you are, the younger you are, and the more muscular you are - the more calories you burn. The rest of the calories burned is based on your level of physical activity with slight contribution from other “thermic” factors such as food intake and exposure to cold. The REE is generally around 10-12 calories per pound for normal weight individuals. There are several ways to estimate daily caloric requirement. If your weight is normal and you just want to maintain your weight, one easy way is to determine your weight in kilograms (divide pounds by 2.2) and multiply by 30. Very active people may need a little more and sedentary people need less but this is usually a close estimate. Most adult women need 1600-1800 kcal/day for weight maintenance and most men need 2000-2200 kcal/day. A more individualized way to estimate daily needs is to use a predictive equation to calculate REE such as the Harris-Benedict Dr. Elise Brett received her medical degree from Mount Sinai School of Medicine. She completed her internal medicine residency and fellowship training in Endocrinology and Metabolism at the Mount Sinai Hospital. She is currently in private practice in Manhattan and is Associate Clinical Professor at Mount Sinai School of Medicine. She is co-editor of the American College of Endocrinology’s Power of Prevention: The Complete Guide to Lifelong Nutrition.
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FAMILY TIES Jamila was diagnosed with type 2 diabetes in 1992. Before her diagnosis, Jamila was no stranger to diabetes and its complications. Jamila’s mother, as well as six of her siblings, had diabetes. At least two of her siblings died from complications related to diabetes. One of Jamila’s sons also has diabetes. So Jamila understood firsthand the consequences of untreated diabetes, and she was determined to stay healthy.
or Mifflin-St Jeor equations which are based on a person’s weight, height, and age. The REE is then multiplied by an activity factor. These equations can be found on the internet. An even more accurate way to determine REE is using a method called indirect calorimetry which measures a person’s oxygen consumption and carbon dioxide production at rest. These days some weight loss clinics and gyms have small handheld devices which measure a person’s oxygen consumption and give a close estimate of REE. Once you have determined your daily energy expenditure, you can eat that many calories each day to maintain your weight or reduce the total amount by 500 per day for weight loss. It is important to understand that there is substantial unexplained variability in these predictive equations that may be due to genetics, ethnicity, weight history or other factors. If these calculations do not work for you, adjust calorie intake up or down based on your body’s response.
Jamila worked for many years at a company in the Northwest. While at work one day, Jamila noticed that she was unusually thirsty. She kept drinking more and more water, but nothing could quench her thirst. A co-worker suggested that Jamila visit her doctor to find out why she was so thirsty. Tests showed that Jamila’s A1C and blood glucose (sugar) levels were extremely high and that she had type 2 diabetes.
It’s important to have the support of my family. We’re fighting this battle together.
Probably the most effective way to determine how many calories you need to eat per day to lose weight is to calculate the amount of calories you have been eating and reduce that by 500 per day. Since 3500 kcal equals one pound, this typically results in 1 pound per week of weight loss. Although this doesn’t sound like much, this is a safe and attainable rate of weight loss. Studies have shown that most women need 1000-1200 kcal per day to lose weight and men 1500-1800.
“The diagnosis was unexpected, but I wasn’t surprised,” she admits.
Looking up calorie amounts helps one pay more attention to foods that need to be eaten in more limited amounts. Plus if a diet is not working, tallying up daily calories can help determine a new caloric target. There are numerous calorie reference sources available in print, online and on handheld electronic devices. The bottom line is: if you want to lose weight, eat fewer calories. P
Jamila spent months looking after the needs of others, and, unfortunately, did not have enough time to take care of herself. She was always on the go. Though Jamila would have loved to cook every meal at home, there just wasn’t time. Jamila’s diabetes was not in control, and it became more difficult to manage her condition with oral medications alone.
At first she was able to manage her condition through diet and exercise. As her diabetes progressed, Jamila started taking oral medications to control her blood sugar levels. Jamila did not let this slow her down. In fact, she became the caretaker for a few ailing relatives.
“I guess you could say I graduated to the next level of management,” she reflects. Jamila started insulin therapy two to three times per day. Initially, she was concerned about taking insulin because she was afraid of growing dependent on it and never being able to stop. However, after speaking with her doctor, Jamila learned that if she loses weight and gets her diabetes under control, eventually she could be able to manage her condition without insulin. There is a new set of rules that Jamila must follow. The first and most important: putting her health first. Jamila’s condition is not yet fully under control. Her blood sugar levels and her A1c level are above the normal range. As the years have passed since Jamila’s diagnosis, it hasn’t been easy for her to maintain energy, but she tries to be as active as she can. And at this time, Jamila reports no major complications from her diabetes. “It isn’t easy living with diabetes,” Jamila explains. “It’s a dayto-day struggle.” Proving that it’s never too late to start being healthy, Jamila is determined to get her diabetes under control and reduce her risk for complications. Now age 71 and retired, Jamila is on a mission to be the healthy person she’s always wanted to be. She visits her endocrinologist [en-doh-cri-NA-lo-jist] often to monitor her diabetes, and she is trying to lose weight. Jamila has reviewed her meal choices and has learned to enjoy cooking at home. She also seeks help from her siblings, who understand her struggles with diabetes. Jamila lives with three of her siblings who have diabetes, each with their own management strategies. One brother is an avid golfer and uses insulin. Another brother uses insulin for diabetes but also has kidney disease, which requires dialysis. Jamila’s sister is a lawyer and professor and takes oral medications to control her blood sugar levels. While she and her siblings manage their diabetes in different ways, she appreciates the encouragement from family members. “It’s important to have the support of my family,” she says. “We’re fighting this battle together.” P
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MAKING EXERCISE
• A reasonable goal is to have blood sugar between 120 and 180 mg/dL before beginning exercise. • If you exercise for more than 1 hour, you should check your blood sugar about every 30 minutes.
PART OF YOUR DAILY LIFE
• Long workouts burn carbs (carbohydrates), so make sure that you consume carbs before and during exercise if the workout is more than 1 hour.
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E’VE ALL HEARD ABOUT THE BENEFITS of exercise: “More energy! Better mood! Weight loss! Lower cancer risk! Stronger bones! Lower cholesterol!” The list goes on and on. So why doesn’t everyone get out there and get with the program for a stronger, happier, healthier, sexier self?! Because it’s a lot of work. Add your diabetes to that and it can be really tough. Exercise takes time. It can be tiring. Blood sugar levels can be all over the place. Hypoglycemia [hie-poh-glySEEM-ee-ah] (low sugar levels) can occur in the middle of a good workout and it can even creep up on you hours later.
• Mix it up. If you’re not training for the Olympics or being paid as a pro athlete, chances are that no one is requiring you to do a specific workout plan. Just keep moving! -Walking, running, dancing, biking, paddling, swimming, skiing, snowshoeing, mowing the lawn (not with the riding mower!), etc. It’s all exercise!
I CAN’T AFFORD TO JOIN A GYM OR BUY EQUIPMENT AND I DON’T LIVE IN THE SAFEST NEIGHBORHOOD
Here are some suggestions to tackle a few of the biggest hurdles to exercise.
Time to use some creativity. Try this:
I HAVE NO TIME
• using the stairs at home
There are 24 hours in the day. On those days when you feel like you just can’t find the time,
• using chairs and other things in your home to create a weight training routine
• park the car farther away from work or get off at an earlier bus stop and walk the rest of the way at a brisk pace
• signing out exercise videos from the library
• use the stairs • carry your kids around • shovel • jog with the dog Scheduling a daily session on your calendar can be helpful. Mornings are good because the day usually hasn’t gotten filled up with surprises yet.
EXERCISE IS BORING Exercise can be boring. The key to sticking with it is keeping it fun. • Have a workout buddy (and a backup one)! A spouse, friend, or neighbor is a good start. • Sign up for a class or group. For example, there are biking groups, running groups, and YMCA water aerobics classes.
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You are more likely to stick to your exercise if you do it with a group on a regular basis.
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• exercising during lunchtime at work
BUT I HAVE DIABETES! COULDN’T EXERCISE BE DANGEROUS? Before beginning an exercise program it is important to have a medical exam and to talk about different types of physical activity with your doctor. Your doctor may have suggestions and restrictions based on your personal health issues.
I’M AFRAID MY BLOOD SUGAR WILL DROP It might. Sweating, racing heart, hunger, nervousness, trembling, headache, and dizziness are early symptoms. Unfortunately, these symptoms can sometimes seem just like a normal effect of a tough exercise routine. The key is to learn your body’s responses to different types and levels of exercise and to check your blood sugar often. You must check your blood sugar before, during, and after exercise.
• If your blood sugar is less than 70 mg/dL, stop exercising and have 15 to 20 grams of a fast-acting carb, like glucose tabs, fruit juice, or honey. It’s important that you carry fast-acting carbs with you in an easily accessible form during workouts. Wait 15 minutes and then recheck your blood glucose. If it’s less than 100 mg/dL, eat another 15 to 20 grams of carbs.
• If you have type 2 diabetes and your blood sugar is higher than 350 mg/dL, do not exercise. Hydrate with a non-carb drink and adjust your medication/dietary regimen.
WHERE CAN I GET MORE INFORMATION ABOUT DIABETES AND EXERCISE? I’m glad you asked! - The Diabetes Exercise and Sports Association (DESA)! For more information and/or to join DESA, go to http:// www.diabetes-exercise.org/. The fact is…every little bit of exercise helps. We all need to make it a priority in our lives. You and the ones you love will benefit by learning how to exercise safely and finding ways to do it regularly. P
• If your blood sugar is dropping and you don’t have an immediate snack, quickly increase the intensity of your workout (for example, start sprinting if you are running). This will cause stress hormones to increase and your blood sugar will go up for a bit while you’re getting glucose. (This is only a short-term solution until you can get a fast-acting carb into your body.) • Remember to check blood sugar more often after starting an exercise program. The effects of exercise often include lower blood sugars many hours after the workout is done. You need to think ahead about changing your medication dosing or snacking so that you don’t get hypoglycemia later on. • Keep track of your blood sugars and your training. This information will help you figure out future insulin dosing, pre-exercise meals, and snacks to have with you. You will notice patterns.
CAN I EXERCISE WHEN MY BLOOD SUGAR IS ELEVATED? • If you have type 1 diabetes and your blood glucose is 250 mg/dL or higher, check for ketones [KEE-tones]. • If ketones are present, do not exercise. You may or may not have DKA (diabetic ketoacidosis [KEE-toe-ah-sih-DOE-sis]), but you should drink a non-carb drink and contact your doctor. • If you have no ketones, and your blood sugar is between 250 and 300 mg/dL, you may exercise very carefully at a low intensity. But, you must continue to hydrate with a non carb drink, and monitor your blood sugar often. • If your blood glucose is more than 300 mg/dL, do not exercise and take steps to improve your glucose control. • If you have type 2 diabetes and your blood sugar is 350 mg/ dL or higher, you may exercise with caution at a low intensity, but continue to hydrate with a non-carb drink, and monitor your blood sugar often.
Dr. Kathryn Ackerman is a sports medicine specialist, endocrinologist, and instructor of medicine at Harvard Medical School. Her clinic is based at Children’s Hospital Boston Sports Medicine. She sees athletes of all ages with musculoskeletal issues, general medical issues, and especially endocrine problems, such as diabetes and female athlete triad (disordered eating, low bone mass, and menstrual irregularities). She is a former national team rower and a current team physician for the US Rowing Team and Community Rowing, Inc. She currently serves on the Board of Directors of the Diabetes, Exercise and Sports Association.
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The Impact of Sleep Disturbances on Diabetes: T H E VA L U E O F A G O O D N I G H T ’ S R E S T INTRODUCTION Sleeping disorders affect everyone from teenagers to the elderly. Not getting a good night’s sleep can have a major negative impact on your health and well-being. Multiple studies show that being deprived of sleep for any reason has negative effects on blood pressure, blood sugar, and fats in the blood. This in turn can lead to poorer diabetes control and complications. We have long known about the need for good nutrition and physical activity to help with diabetes. Good sleep is also important for your health and well-being. Lack of sleep is common in adults with type 2 diabetes. This is partly because more of this group has obesity, and partly because of other factors, not fully understood, about diabetes. So, it is important that every person with diabetes and their families have an understanding of sleep issues and whether it affects them. This article will briefly review the various causes of sleep deprivation, show how it affects diabetes, and suggest how some sleep problems can be managed.
CONSEQUENCES OF LACK OF SLEEP Daytime drowsiness is the most obvious result of poor sleep. This is not only unpleasant, but it has also been shown to increase one’s risk of accidents and to affect judgment and performance. The majority of fatal car accidents that are not caused by alcohol intake are believed to be caused by people either falling asleep at the wheel or being too tired to handle a situation. Medical interns and residents are no longer allowed to work as many hours per week as in the past because it was shown that they begin to make mistakes when fatigued, mistakes that can have grave consequences. Airline pilots have long known this. Research shows that we eat differently when we are sleep deprived. In carefully conducted experiments, healthy volunteers were deprived of half their usual sleep time for several days. They began to eat more calories overall and to chose more calorie-dense food (junk food). It is difficult to exercise as hard or as long when we are tired. Lack of sleep makes it difficult to make the best choices in lifestyle for control of diabetes. Sleep deprivation affects the major risk factors for heart disease. These risk factors include elevating blood pressure, raising triglycerides (fats), lowering HDL cholesterol (the good cholesterol), raising adrenaline and vascular inflammation, and directly raising glucose (blood sugar). Successfully treating sleep problems improves all these risk factors. Recent published research shows improvement in cardiovascular outcomes in sleep
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apnea patients who were successfully treated compared with those who were not.
TYPES OF SLEEP PROBLEMS As with food or exercise, we are able to tolerate short-term deviations from healthy behavior without great consequence. It’s when the deviations become chronic that more serious issues begin to develop. Perhaps the most common cause of sleep deprivation in the United States is self-inflicted. We simply don’t give ourselves enough time to sleep or we allow too many distractions during sleep, such as pets or children sleeping with us, TV and radio being left on overnight, and so on. Many of us stay up late at night for work or entertainment, and then force ourselves awake with an alarm clock and coffee. As a population we sleep, on average, about 90 minutes less than our grandparents. People who travel across time zones have long known about the impact of jet lag. A similar fact occurs in people who work alternate day and night shifts. The quality of sleep varies with stress, alcohol intake before bed, coffee intake, many medications, and even temperature of the room and number of bed covers. Insomnia and fitful (fragmented) sleep is a common complaint. The many ads for sleep aids are evidence for how disturbing a problem this can be. Heavy meals and heavy exercise before bedtime can disrupt sleep. Many women report worsening of sleep when they are entering menopause. Restless leg syndrome (RLS) is increasingly being recognized as a medical cause of sleep disturbance and medication can be quite successful in relieving it. The most studied form of sleep disturbance is sleep apnea.
SLEEP APNEA Sleep apnea is a condition in which a person stops breathing many times during sleep and wakes up needing oxygen. Since the person wakes for a very short time, people with sleep apnea usually do not know they have lost sleep, only that they wake up tired and stay tired all day. Very loud snoring is one sign that sleep apnea is present. The most common type of sleep apnea is obstructive sleep apnea (OSA) caused by physical blockage of the airway during sleep.
B Y D A N I E L E I N H O R N , M D , F A C P, F A C E
OSA is more common in obese people, in men, and in the elderly. In our study of the prevalence of OSA in adults with type 2 diabetes, we found that while less than 20% of women below age 65 had OSA, over 60% of men above age 65 had OSA. There are studies showing that treatment of OSA in those with diabetes can lower fasting and post-meal blood sugar and A1C as much or more than any oral medication.
HOW TO FIND OUT IF YOU HAVE SLEEP PROBLEMS When I ask my patients about sleep, I begin with “Do you wake up refreshed?” That, more than the absolute hours they sleep, clues me in to whether a sleep problem may be present. Insomnia or fitful sleep is usually obvious, but people may not want to mention it because they think nothing can be done. The bed partner is usually needed to report on abnormal breathing or movement during sleep. Loud snoring is a common symptom of sleep apnea. The bed partner (if not forced away by the snoring) typically observes periods of not breathing followed by loud grunts and gasps for breath. This usually goes on all night. The person usually has daytime drowsiness and falls asleep whenever it is quiet. When a patient falls asleep in the waiting room, that’s a clue! That this may go on for years is also a clue to how forgiving, or how denying, bed partners can be. When sleep apnea or RLS is suspected, the usual course is to refer their patient to a sleep specialist. Doctors of many different backgrounds have begun to specialize in sleep problems, and there is increasing acceptance of the need for consultation. The specialist may choose to do an overnight study in a sleep lab, a facility that looks more like a hotel than a lab. Depending on what is suspected, the study may include measurements of oxygen in the blood, brain waves, movement, and other tests.
TREATMENT OF SLEEP DISTURBANCES Perhaps the toughest disturbance to treat is voluntary sleep deprivation. People just don’t change their sleep habits easily, much as with dieting or exercise. I encourage people to at least try a brief period of increasing their sleep time by going to bed at least one hour earlier for a week. When they do it, the results are sometimes dramatic and avoid the hassle and expense of multiple tests looking for a cause of fatigue. Controversy continues over the use of sleep aid pills, but most clinicians are comfortable with them. The more recent sleep aids do not appear to have a large risk of dependency or addiction. Fatigue from jet lag or changing work shift times is difficult to treat and so there are many proposed remedies. Most agree that avoiding caffeine and alcohol helps. So does shifting to the new time zone on arrival. A recent review published in the
New England Journal of Medicine encourages light exposure (for waking up in a new time zone) and melatonin (for encouraging sleep in a new time zone). RLS can usually be successfully treated with medications. OSA is currently best treated by continuous positive airway pressure (CPAP). CPAP involves a mask worn over the nose that blows air with a high enough pressure to keep the airway open. It is not always easy to get the right level of comfort and effectiveness, and some people cannot tolerate it. But when CPAP is successful it can dramatically improve a person’s quality of life. Certain people with OSA may need surgery to widen the airway or may even need a device that repositions the jaw.
CONCLUSION Sleep disturbances are very common in people with diabetes, and they are usually readily diagnosed and successfully treated. This is a matter of both quality of life and of basic health issues that are so critical to a health circulatory system. Blood sugar, blood pressure, lipids, and virtually all factors associated with diabetes are affected by sleep disturbances. P
Dr. Daniel Einhorn is President Elect of the American Association of Clinical Endocrinologists, President of Diabetes and Endocrine Associates, a Clinical Professor of Medicine at the University of California San Diego, and Medical Director of the Scripps Whittier Diabetes Institute, in La Jolla, California. He was the 2005 recipient of the Yank D. Coble, Jr., MD, Distinguished Service Award from the American College of Endocrinology and Guest Editor of the Endocrinology and Metabolism Clinics of North America for Type 2 Diabetes.
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D EPRESSION: A Common and Treatable Condition in Individuals with Diabetes B Y PA U L C I E C H A N O W S K I , M D , M P H
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epression is a common condition that can be debilitating. However, depression is highly treatable. Depression is twice as common in those with diabetes as the general population. About one third of people with diabetes will have an episode of significant depression sometime during their life. Depression is important to recognize and treat because it can lead to declines in function. In those with diabetes, depression often leads to worsening of physical symptoms, poorer adherence to treatment and self-care, and poorer health status overall.
How can depression have such a large impact on people who have it?
DEPRESSION: MORE THAN SAD MOOD People think of depression as a condition in which someone has a sad or “blue” mood for weeks at a time. This is true, but it explains only part of the many symptoms that people may experience when they are clinically depressed. In fact, some depressed people may not even experience a sad mood! For example, some people with depression may lose their interest in things that used to bring them pleasure, such as having hobbies or being with friends, but they might not have a depressed or sad mood. Clinically depressed people also have other important symptoms, such as abnormal sleep patterns. This abnormal sleep may happen when the person is feeling depressed, or may happen before the person feels depressed. Some people with depression can’t sleep well early in the evening or during the night, and others cannot seem to get enough sleep. Dr. Paul Ciechanowski is an Associate Professor of Psychiatry at the University of Washington where he is also Associate Director of the Psychosomatic Medicine fellowship. He was a board-certified family physician before becoming a psychiatrist and was recently funded through a NIDDK Career Development Award to study patient-provider relationships, treatment adherence and outcomes in diabetes and other chronic illnesses. He has published extensively in the area of depression and diabetes and combines his experience in psychiatry and primary care in his clinical psychiatric work in the Diabetes Care Center at the University of Washington.
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Depression can have a large impact on appetite. Most people with depression aren’t hungry and lose weight. But others are often hungry, crave carbohydrates (carbs) and gain weight. Clearly, such appetite changes can impact people with diabetes who are trying to maintain their blood sugars. Other common symptoms of depression include fatigue, poor concentration, nervousness and irritability, worsening of physical symptoms and pain, and loss of sex drive. Twenty percent of depressed individuals experience panic, or anxiety attacks. Often, in people with diabetes, these symptoms are mistaken for worsening of diabetic symptoms. This leads to frustration because patients and their families believe that their diabetes is getting worse. For the depressed patient, the increased guilt and lack of hope that often accompanies depression may make the person more frustrated. Untreated depression can also lead to very serious consequences. Some people with depression can become so hopeless that they may think about taking their own life. Some unfortunately do.
WHAT CAUSES DEPRESSION? Why depression occurs in people with diabetes varies from patient to patient. For example, a family history of depression, overuse of alcohol or other substances, or marital stress or loss of a loved one can all contribute to depression. Certain thought patterns and coping styles can also make someone likely to get depression or continue to have depression. The stress of coping with a chronic illness such as diabetes can contribute to depression. For example, dietary restrictions, recurrent hospitalizations or long-term complications may all lead to increased stress and cause the person to get depressed. Current research suggests that changes in the brain’s neurotransmitters [NOO-row-TRANZ-mit-terz] (nerve cell chemicals) are what cause depression.
WHAT DOES DEPRESSION CAUSE? People who don’t get treated for their depression may be less productive, miss work, feel physical and emotional distress, and are likely to go to their doctor much more often. People with diabetes and untreated
depression are likely to not monitor their blood sugar properly or take their medications regularly, may not follow their diet or exercise program, and may lose their concentration and feel hopeless. All of this can affect blood sugar control and cause diabetes complications. Depression can also worsen physical symptoms. In other words, people with medical symptoms, such as burning pain of the feet, can become unable to deal with their symptoms when they’re depressed. Overall, untreated depression can negatively influence one’s quality of life in significant ways.
DIAGNOSIS AND TREATMENT OF DEPRESSION Doctors are trained to recognize and diagnose depression. However, in the early stages of depression, the patient or patient’s family needs to alert the doctor about the symptoms, since these early symptoms are not always clear to others. The doctor will look for signs and symptoms of depression and will also ask about the patient’s past medical and psychological health, and about depression in blood-related family members. Doctors may want to do a physical examination. They may order laboratory tests to rule out medical causes of symptoms that seem like depression or cause depression. Patients are usually treated with antidepressant medications and/or psychotherapy [sike-oh-THER-a-pee] (e.g., counseling). These kinds of therapy can be done alone or together, but they usually work better together. The newer antidepressant drugs target more specific neurotransmitters in the brain, such as serotonin, than older antidepressant agents. These newer agents are safer, more easily tolerated, and have fewer side effects than the previous types of antidepressants. Just like oral hypoglycemic medications and insulin can decrease diabetes symptoms by making blood glucose levels normal, so too can antidepressant medications gradually minimize symptoms of depression and restore function by changing the levels of neurotransmitters. Antidepressant medications are usually taken by mouth once or twice a day. They’re not addicting and patients usually feel better in two to six weeks. Patients and their families need to realize that it may take this long to get relief, so they shouldn’t get discouraged. Psychotherapy done at the same time as medication therapy helps speed up relief of symptoms and makes it less likely that depression will come back. Treatment of depression gradually restores one’s mood. It can also restore normal sleep and eating habits, increase one’s energy level, and improve concentration, among other things (see Box). Treating depression also helps people with diabetes manage their symptoms and blood sugars better. If you or a family member is experiencing symptoms of depression, bring it up with your health care provider. Depression is recognized more and more as a serious condition that can adversely affect individuals with diabetes. Fortunately, depression is also a condition that can be effectively treated. P
POTENTIAL BENEFITS OF DEPRESSION MANAGEMENT IN DIABETES • Better mood, less anxiety • Better sleep and eating habits • Increased physical activity, better job performance, better social interaction • Less pain; better able to handle chronic pain • Better day-to-day ability to care for diabetes and/or diabetes complications • More interest in sexual activities adapted from Lustman et al., 1997
VITAMINS, MINERALS, SUPPLEMENTS… Maybe a Potion or Two Would Work for Me? BY DACE L. TRENCE, MD, FACE
How often have you seen an advertisement for a product that promises to control your diabetes or diabetes-related problem such as elevated cholesterol and have been tempted? You may have even purchased the product and then become concerned that it may not be effective or even safe to take. Maybe you’re not sure how much to take. Perhaps you decided to take the product any way and see what happened. From studies, at least 60%-75% of people with diabetes have tried at least a supplement or vitamin specifically to treat their diabetes or diabetesassociated condition at some time. Some products that in the past were considered “supplements” have become the basis for prescription medications. For example, goat’s rue, used in past centuries for the treatment of elevated blood sugars, today would more readily be recognized as the prescription drug metformin. Yet many others have fallen by the wayside as their effectiveness or toxicity have made the agents unusable.
Dr. Dace Trence is Director of the Diabetes Care Center and Associate Professor of Medicine at the University of Washington Medical Center in Seattle. She is also the University of Washington Endocrine Fellowship Program Director and Director of Endocrine Days, a medical education program for endocrinologists practicing in the Pacific Northwest. She is on the American Association of Clinical Endocrinologists Board of Directors,POWER and chairs CME Committee. 21 OFthe PREVENTION • VOL. 2, ISSUE 2
The Power of Volunteering for Clinical Research BY SAMUEL DAGOGO -JACK, MD, FACE
A volunteer is someone who chooses to do something freely. Volunteers give freely of themselves, their time, and their resources. Many of you have donated your time, energy, money, and other resources to one cause or another, for the greater good. However, there is another aspect of volunteering you should know about. Volunteers in clinical research have allowed modern medicine to advance. You may be surprised to know that until very recently, doctors had very little scientific facts or proven remedies to offer their patients. What moved the practice of medicine from the “dark ages” to the modern medicine of today are the advances in medical research and the people who volunteered for those studies. Generally speaking, four elements come together to make for successful clinical research and discovery of new scientific breakthroughs. First is the scientist who comes up with an idea. The idea must be unique and able to be tested. Second is where the research takes place. That environment (including the groups overseeing the research and the group conducting the research, material support, laboratory, physical location, etc.) must support the growth of new ideas and must allow the proposed research study to be conducted. Third is adequate funding. This usually comes in the form of a research grant. However, many great discoveries and breakthroughs came from a cash-strapped genius who worked alone in a crowded shack. For instance, in the 1920s Frederick Banting led a research team at the University of Toronto that discovered insulin, which radically improved the fate of millions of people around the world. His research was not funded by any major grant. He got loans from his father and brother so that he could keep working on his research. Other noteworthy people who did not get large grants to fund their research were the Wright brothers and Einstein. However, Dr. Samuel Dagogo-Jack takes care of patients with diabetes and endocrine/metabolic disorders at the University of Tennessee Health Science Center, Memphis, Tennessee. He is also Professor of Medicine and Chief of the Division of Endocrinology at UTHSC, and Director of the Clinical Research Center. Dr. Dagogo-Jack’s research focuses on the prediction and prevention of diabetes and prediabetes. He is an Editor for the Journal of Clinical Endocrinology and Metabolism and Associate Editor for Diabetes Care. Dr. Dagogo-Jack has published 16 book chapters and more than 200 scientific papers and abstracts.
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clinical studies these days are critically dependent on large grants because research is extremely expensive and complex. Fourth and the most important engine of clinical research are the selfless men and women who volunteer to serve as research participants. For example, after furious and demanding hard work through most of 1921, Dr. Banting’s group finally produced a crude “insulin” extract from animal pancreas and needed to test whether it would work. In January 1922, Leonard Thompson, a teenager with diabetes, became the first human being to receive an injection of the crude insulin extract. The result was astounding. For the first time ever it was clear that an extract from animal pancreas had an “antidiabetic” effect on a human. After that finding, researchers perfected the crude insulin extract and mass produced it for use in patients around the world. Leonard Thompson was the first volunteer in human research regarding insulin treatment. In 1948, the Framingham Heart Study was launched. Its goal was to identify “the common factors that contribute to cardiovascular disease by following its development over a long period of time in a large group of participants.” A total of 5,209 adult residents of Framingham, Massachusetts, signed up. That group of volunteers made endless visits to the research center, gave countless specimens of blood and body fluids, underwent repeated clinical exams, and passed on the baton to their children and grandchildren. The Framingham Heart Study now follows the descendants of the original volunteers! The study has given us great insight into risk factors for heart disease. Much of what we know today regarding the effects of high blood cholesterol, blood pressure, obesity, diabetes, and other factors on the development of heart disease can be traced to discoveries made in the Framingham Heart Study. Another example, the Nurses Health Study, was launched in 1976. Approximately 122,000 nurses volunteered to respond to questions about diseases and health-related topics, including smoking, hormone use, and menopausal status. The volunteers answered these questions repeatedly for the study over many, many years. The results have been published in multiple scientific journal articles and have led to a greater understanding of women’s health. The Physicians Health Study, started in 1982, provided information regarding the benefits of aspirin in prevention of cardiovascular disease. The study showed that low-dose aspirin decreased the risk of a first heart attack by 44%. More than 25,000 doctors volunteered for that study.
The power of volunteers is clear in several clinical trials in diabetes. The Diabetes Control and Complications Trial (DCCT), started in 1983, enrolled 1,441 patients. These volunteers have been attending research clinics for nearly 30 years! After the initial 10 years, the name of the study was changed to EDIC (Epidemiology of Diabetes Interventions and Complications) and the original volunteers were asked to stay in the study. I recently saw one man in his early 40s at a follow-up visit at our University of Tennessee site of the DCCT. He joined the study at age 15, and he has been coming ever since! DCCT volunteers had to follow a strict regimen of frequent home blood sugar (glucose) testing, multiple daily insulin injections, and frequent contacts with the research teams. Because of the volunteers, researchers in the DCCT study made the important discovery that good blood sugar control results in A1C levels of 7% or lower, and helps prevent the development of diabetic complications in the eyes, kidneys, and nerves. The continued participation by the volunteers has enabled the study to make additional discoveries on the impact of blood sugar control on heart disease, bladder function, and other conditions. Together, diabetes and pre-diabetes affect about 80 million Americans. Of these, 54 million persons have pre-diabetes, a condition in which the blood sugar is abnormal but not severe enough to qualify as diabetes. Today, diabetes is treated with a wide variety of medications, all of which were discovered through research involving volunteers! Used properly with healthy eating and an active lifestyle, these medications help control high blood sugar and prevent tissue damage that can lead to diabetic complications (such as blindness and kidney failure). However, researchers have decided that it is smarter to prevent diabetes from occurring in the first place. The critical discovery on how best to prevent type 2 diabetes owes its very existence to more
than 3,000 study volunteers for the Diabetes Prevention Program (DPP). The DPP study, sponsored by the National Institutes of Health, discovered that people with pre-diabetes develop diabetes at a rate of about 10% per year. However, with modest changes in lifestyle (walking 30 minutes, five times weekly, and decreasing calories), the rate of progression from pre-diabetes to diabetes was cut nearly 60%. The DPP inspired our ongoing Pathobiology of Prediabetes in A Bi-racial Cohort (POP-ABC) Study at the University of Tennessee Health Science Center. In this study, we’re focusing on the early stages before even pre-diabetes develops. This way we can better understand the triggers that create abnormal blood glucose levels. Nearly 400 African American and white volunteers have joined the POP-ABC study. Knowing the triggers would enable future development of better targeted interventions. This will allow us to prevent early abnormal blood sugar levels. The cure for this epidemic of our time—diabetes— can only come from well-directed research to find the earliest root causes of the problem. Clearly, taking new scientific ideas and making them clinically relevant breakthroughs cannot occur without volunteers for medical studies. Without research volunteers, the best ideas and projects would be “dead in the water.” The volunteers in the DPP who helped us make the important discoveries and other research volunteers in other projects represent the brightest hope of humanity. They share their time generously with society. They follow study protocols, and in the process generate results. Although volunteers tend to join studies because they are concerned about their own health, they help further research to help others in the future. In that regard, our research volunteers are indeed worthy ambassadors of science. In the effort to find an answer for the diabetes epidemic, we salute the contributions and sacrifice of all those who have served as VOLUNTEERS for research projects. P
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WORD BANK:
_______ DIABETES
EXERCISE HEALTH
**
SOLUTION:
*
*
3. Shaped like a red ball with a leafy green hat; I can be sliced, diced and added to stew; Loaded with vitamins C and A; I’m a great source of potassium and fiber too.
(OVER,DOWN,DIRECTION) BLOODSUGAR(10,6,W) DIABETES(2,9,E) DOCTOR(3,2,SE) EXERCISE(9,4,W) HEALTH(9,3,S) INSULIN(2,8,E) METER(8,5,W) NUTRITION(1,9,N)
2. I have many ears, but cannot hear; as a cob I’m a popular side; A great source of fiber for those who eat; my kernels are my pride.
*
This was written when I was an undergraduate college student working on a summer job in a VA endocrine research lab. The veterans and their families would see the word endocrinology lab on the door and ask…”What is an endocrine?” + + + + + B + + + +
1. I’m the topping on a sandwich; the “L” in BLT; I’m full of potassium and vitamin A; it wouldn’t be a salad without me.
+ + H E A L T H S +
*
Pretty small, this endocrine, And yet it keeps us "in the spin," From all our systems, it makes a whole, Through principles of demand control.
+ + + X M O R N E +
METER
WHAT AM I? _______
Calories Daily Values Fat Nutrition
The master gland, it has been shown, Control our size with growth hormone, And through a manner quite complex, It regulates our glands of sex.
INSULIN
Ever wondered what that white box on the side of a food package is? This is the nutrition facts label, which is filled with important information you need to know about the foods you eat.
WORD BANK
And should the thyroid gland be slow, The pituitary starts to go, Setting forth another juice, Which lets the thyroid hormone loose.
DOCTOR
KNOW THE FACTS!
Fill in the blanks of this nutrition label using the word bank.
The adrenal gland begins to roar, Hydroxy-steroid levels start to soar, Soon we’re ready to conquer all, Supercharged with cortisol.
BLOOD SUGAR
NUTRITION
*
When e'er the outside world gets rough, This master gland secretes a stuff, Which gives us all a helping hand, By stimulating our adrenal gland.
+ + + E E O + I T +
R N K B Y Y P J Q G D S X P Y H Q G Q Z O D C H B H G E S I C R E X E B W E R E T E M A O A G U S D O O L B Q A J K Y K R T J I N S U L I N H H D I A B E T E S E B Y C L I K B U A
*
*
*
`
+ + + R T D + L E +
N O I T I R T U N R
*
Just beneath the middle brain, Resting near the portal vein, Is a tissue, small and thin, The pituitary endocrine.
+ + + D + + + O + S I C + R E G U S + + + N S U I A B + + +
WORD SEARCH ___________
*
By Arthur N. Lurvey, MD, FACP, FACE
+ + + E + A + I D +
*
KIDZ ZONE
WHAT IS AN ENDOCRINE
N O I T I R T U N +
*
*
Protein Serving Sugars Vitamin
ANSWER: 1. LETTUCE; 2. CORN; 3. TOMATO
Continued from page 8 An endocrinologist does clinical research, some of which is published and is viewed by all of the medical community. Endocrinologists help develop diagnostic and treatment guidelines. So as you look for a doctor to help you with your diabetes health issues and questions, look for an endocrinologist, the specialist in the care of hormone disorders, such as diabetes and weight disorders! P Continued from page 8 How is your doctor working to improve health literacy? Do you recognize some of the strategies your doctor is using to improve understanding? Your doctor should: • cover a few key points at each visit • use clear language • clarify concepts with pictures and drawings
• confirm your understanding by “teach-back” or “show me” method • go through a few practical examples
Communication is the key to your health success! Don’t be afraid to ask questions.
P
Continued from page 10 • http://www.diabetesincontrol.com/ This site has weekly updates on newly published research, newly published reports on drugs, and national meeting highlights pertaining to topics related to diabetes diagnosis, care, and management. Free. • http://diabetes.niddk.nih.gov/ A resource sponsored by the National Institutes of Health for information about diabetes and its complications and conditions. Many links to other Web sites related to diabetes, even to Web resources in different languages. Free. • http://diabetes.webmd.com/ A very patient-friendly resource for questions about the diagnosis, management, and treatment of diabetes and various diabetes-associated conditions. Contains questionnaires that can help you understand if symptoms might be related to a diabetes condition, and when to discuss these with your health care team. Information also available about pre-diabetes. Includes videos of patients with diabetes discussing their diabetes. Additional links to other health care information. Free.
LETTERS
FROM READERS Question: I was just diagnosed with type 2 diabetes by my primary care physician. He said that I need to find an endocrinologist to get my diabetes under control. How can I find a list of endocrinologists in my area who specialize in diabetes?
—Glenn B Read how Glenn found the motivation to change at ChangingDiabetes-us.com/voices
Answer: We’d love to hear from you! Simply e-mail us at feedback@powerofprevention.com and tell us your success story. Question: I found your magazine in my endocrinologist’s office. I’ve heard that previous issues covered thyroid dysfunction and obesity. I’d like to see more information about other conditions, such as parathyroid disorders or Polycystic Ovarian Syndrome (PCOS). Can I suggest a topic for an upcoming issue?
• http://www.cdc.gov/diabetes/ A resource sponsored by the Centers for Disease Control and Prevention (CDC) that contains information pertaining to diabetes in general, but also how to prepare for natural emergencies and disasters if you have diabetes. It also explains the importance of vaccines and provides information for caregivers of those with diabetes. Some information also available in Spanish. Free.
Question: Where can I find previous issues of Power of Prevention Magazine and read more about endocrine conditions?
POWER OF PREVENTION • VOL. 2, ISSUE 2
Question: I have read other issues of Power of Prevention Magazine, and I’m very passionate about getting involved with the program. How can I share my story?
Answer: We love to hear from our readers and we are always open for suggestions. If you have an idea for a topic you’d like to see in the magazine, simply e-mail us at feedback@powerofprevention.com.
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A year ago, I exercised sometimes, but it was always grudgingly, and any excuse was a good excuse to skip a workout. My colleague encouraged me to just try walking some or all of a 5K race. I ran (and walked) several races since then. My blood sugar is much more controlled and I’ve lost 10 pounds.
Answer: It’s easy! Just visit www.aace.com and click on resources and go to “Find an Endocrinologist.” This tool will allow you to search for an endocrinologist by location (either City/State or ZIP code) and/or by specialty (such as “diabetes mellitus”).
• http://www.diabetes.org/ Information about the diagnosis, management, and treatment of diabetes. Contains detailed information about meal choices and healthy foods. Has a link that allows for review of diabetes support groups available in your specific location. Free.
This information is provided to you from public domain resources, and represents just a handful of potential tools to assist the patient with diabetes improve their care and long-term prognosis. None of this is designed or intended to diagnose, treat, or recommend specific advice for any patient. AACE strongly recommends consulting with your doctor and health care team before using any of these tools. P
“ Something had to change…“
i’ve never met Glenn, but reading his story today inspired me to change my tomorrow Visit ChangingDiabetes-us.com to hear dozens of inspirational stories, including Glenn’s. You can even add a story of your own to inspire and motivate someone else. And because managing your diabetes is more than managing your blood sugar, you’ll also discover ideas for healthy lifestyle changes, including a personalized menu planner, tips for staying active, and help setting priorities. And best of all—it’s all free!
Answer: Visit www.powerofprevention.com, the one-stop-shop for health information from the American College of Endocrinology. Here you can download issues of the magazine and link to resources about diabetes, thyroid dysfunction and many other endocrine conditions. © 2009 Novo Nordisk Inc.
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April 2009
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Thank You The ACE Power of Prevention is funded through a grant from Novo Nordisk as part of its Changing Diabetes Leadership Initiative. Novo Nordisk is dedicated to changing diabetes by acting as a partner and catalyst for change in its mission to improve the way diabetes is managed and, ultimately, defeated.