2009 Fall Vol 30

®

Volume 30, Third Quarter 2009

REDEFINING THE DIABETES DOCTOR VISIT Dr. Edelman’s Corner

inTHISissue 1 Dr. Edelman’s Corner 3 Is It Murder? Part 2 5 Question of the Month Control of 6 Taking Hypoglycemia Kim Lyons, Celebrity 8 Fitness Trainer 10 Let Your Energy Lift You Discourse 12 Diabetes Hosted by Dr. Edelman

hen it comes to diabetes care in this country, healthcare reform is urgently needed to more effectively and efficiently prevent, diagnose and successfully treat this increasingly common chronic condition. Careful evaluation of what works and what doesn’t work will be needed to properly address the burden of diabetes that currently affects the lives of 23 million Americans, in addition to another 50-60 million individuals with “pre” diabetes.

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Of all the different aspects of diabetes care that we need to improve, re-defining the diabetes doctor visit has the potential to allow those precious few minutes in the exam room to make a significant impact on clinical care and overall satisfaction for people with diabetes (PWD) and healthcare providers.

In medical school, we are taught the art and science of performing a history and physical (H&P) exam. The format is fairly rigid, methodically marching

through a series of questions and maneuvers in chronological order. It starts off with the history of present illness (HPI), which is a summary of the patient’s main problems, going through each one in terms of what has changed since the last visit and the current status. Next is the past medical history (PMH), which requires a listing of all current and past medical and surgical conditions including medications, allergies, smoking and drinking habits,(Doctor social Visit, situation and continued on much page 2)

Special Acknowledgements Medical Advisory Board Chair: Ingrid Kruse, DPM Veterans Affairs Medical Center Alain Baron, MD CEO, Ethos Pharmaceuticals John Buse, MD, PhD University of North Carolina Jaime Davidson, MD Dallas, TX Mayer Davidson, MD Drew University Daniel Einhorn, MD Diabetes & Endocrine Associates Robert Henry, MD Veterans Affairs Medical Center Irl Hirsch, MD University of Washington

Board of Directors Steven V. Edelman, MD Founder and Director, TCOYD Sandra Bourdette Co-Founder and Executive Director, TCOYD S. Wayne Kay CEO, Response Biomedical Corp.

Margery Perry Terrance H. Gregg President & CEO, DexCom, Inc. Daniel Spinazzola President, DRS International

Contributing Authors Steven. V. Edelman, MD Riva Greenburg Kriss Halpern, JD Michele D. Huie Christine Luu Candis Morello, PharmD, CDE

TCOYD Team Steven V. Edelman, MD Founder and Director Sandra Bourdette Co-Founder and Executive Director Jill Yapo Information Manager Michelle Day Meeting Planner Antonio Huerta Health Fair Manager Michele Huie Communications and Outreach Manager Alice Howe CME Manager Julia Lafranchise Program Support

MyTCOYD Newsletter Michele Huie, Editor in Chief Design: Hamilton Blake Associates

MyTCOYD Newsletter is offered as a paid subscription of Taking Control of Your Diabetes. All material is reviewed by a medical advisory board. The information offered is not intended to constitute medical advice or function as a substitute for the services of a personal physician. On the contrary, in all matters involving your health, TCOYD urges you to consult your caregiver. ©2009 All rights reserved.

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Doctor Visit (continued from page 1) more. Then there is the review of systems (ROS) in which questions are asked about every organ system in the body from head to toe. You may be asked if you have been having any headaches, chest pain, shortness of breath, skin rashes, stomach problems, etc. All of this is followed by a detailed physical exam (PE) which, if completed in a thorough manner, can take quite some time. The laboratory results are reviewed next and then there is the grand finale, the assessment and plan (A&P) for each individual problem. This last section is a mini-summary of the entire H&P and includes all of the medication adjustments to be made as well as tests and consults that will be needed either immediately or before the next visit.

Oh yeah…don’t forget that new prescriptions and refills may be needed.

I hope you are beginning to see the picture I am painting for you.

All of this in a typical doctor visit?

When it comes to dealing with a person living with diabetes, our formal evaluation process is quite ineffective, inefficient and cumbersome, wasting a lot of precious time. Part of the problem is that most health care professionals spend less than 2% of their training learning about diabetes management and do not know what questions to ask or how to ask them. In addition, insurance companies may not pay the provider for services unless there is documentation in the chart that all of the perfunctory items in a typical H&P have been addressed and completed, even if they do not pertain to the most crucial aspects of diabetes care! Lastly, the time allotted for an appointment is

Steven Edelman, MD Founder and Director Taking Control Of Your Diabetes

too short and should be adjusted upward for a diabetes appointment.

We need to individualize the diabetes visit and prioritize the most important issues in order to address the emotional, physical and medical barriers limiting successful diabetes management. I believe the patient’s questions and concerns should be addressed first and not left to the last few seconds as the doctor hurries off to the next exam room. Listening, instead of asking a series of standard non-diabetes related questions, is the best way to start an evaluation. The bulk of the available time needs to be spent on what is limiting the PWD from achieving an A1c value below 7%, including reviewing home or continuous glucose monitoring results, addressing dietary struggles and any difficulty maintaining a regular exercise program, as well as achieving appropriate blood pressure and cholesterol levels. I want my patients to walk me through a typical day in their lives in order to get a grasp of what could be the main limiting factors in getting to goal. The sensitive issues of depression, erectile dysfunction and other psychosocial problems must be discussed openly and as often as needed.

If appropriate, the significant other, or “type 3”, should be there to listen, learn and ask questions that relate to their loved one living with diabetes. Diabetes cannot be treated in a vacuum because (Doctor Visit, continued on page 12)

By Kriss Halpern, JD

n the last issue we described three hypothetical incidents where a car accident caused by a driver suffering severe hypoglycemia resulted in a death. We left for this issue the question of whether any of the drivers might properly be charged with murder.

I

In the first hypothetical raised previously [none of these hypotheticals are based on an actual incident], the driver accidentally took a shot of fast acting insulin instead of the slow acting he uses as basal coverage; he went for a long drive; he suffered a severe reaction; he got into a car accident; someone was killed.

In this case, the driver did not knowingly do anything wrong. The severe hypoglycemic event was the result of a mistake. There was no intentional act. There was no plan to harm anyone. Thus, it appears obvious that murder could not reasonably be considered. But reason does not always control events when someone is killed. Police and prosecutors can be under extraordinary pressure when an innocent person dies. Loved ones want and deserve an answer: something to explain their terrifying loss; some despicable criminal to blame. When questions are asked and answers demanded, things are often not so black and white.

If a murder charge is not

similar situation…”

A driver with diabetes who accidentally takes the wrong insulin has not had a “conscious disregard” for anything. He was not conscious of the error so recklessness does not appear to be an appropriate charge. appropriate because there was no Such a driver also might not be intentional effort to kill, some lesser deemed negligent since a reasonably charge would have to be considered. prudent person with diabetes taking In California, there are two types of insulin might very well have done vehicular manslaughter. The first is the same thing. There is an felony manslaughter which requires argument, however, that a person recklessness. The second is a who accidentally takes the wrong misdemeanor which requires insulin was legally negligent since negligence. Both also most people who A driver with diabetes require an unlawful take these insulins who accidentally takes the traffic event. The do so every day wrong insulin has not had erratic driving that without making a “conscious disregard” preceded the accident this particular for anything. may qualify. In Black’s error. At the Law Dictionary reckmoment of the mistake, it seems lessness is defined as, obvious that the driver was not “the creation of a substantial and reckless and at least arguable that unjustifiable risk of harm to others he was not even negligent. This and by a conscious (and sometimes driver did nothing at all that he deliberate) disregard for or indifferknew was wrong at the time and it ence to that risk; heedless; rash. does not appear that he did anything Reckless conduct is much more especially willful in making the error. than mere negligence; it is a gross However, if the driver recognized deviation from what a reasonable his mistake at the time, how did he person would do.” allow himself to drive afterwards?

Negligence is defined as, For his own safety he would have to “the failure to exercise the standard treat the low immediately; glucagon of care that a reasonably prudent or cans of juice and glasses of milk person would have exercised in a or food with high carbs would be

[

]

(Is It Murder?, continued on page 4) Taking Control of Your Diabetes 3

Is It Murder? (continued from page 3) needed; an urgent call to a physician dosages is not automatic and mistakes might be needed as well. If the driver are made by all of us. Drinking ignored these obvious needs and went certain amounts of alcohol is always and inevitably dangerous. Taking driving instead, this might well be a case of criminal recklessness. Is there certain amounts of insulin might be dangerous one moment and perfectly a defense to such an act? Of course, proper at another. but one would need to know much Third, because insulin is needed more. Was the driver suffering from some mental incapacity as a result of for survival and because it is not always obvious when it might be the mistake? Did he comprehend taken excessively, the idea that what he had done? Did he decide to someone recklessly or knowingly drive to a hospital and end up in an took it to excess is far more difficult accident along the way? These are some of the questions that need to be to determine. It would be a rare and odd case when someone considered before you can assess knowingly and whether there was A mistake in insulin dosage intentionally took criminal responsibilalone is not a criminal act. insulin to excess. ity, because each of them go to the question of knowledge The same is not true for alcohol.

Insulin is taken for the purpose of and intent relating to the event. converting carbohydrates to energy; I have met with prosecutors who it is not taken for pleasure or enterargue that a person who knowingly tainment; it is not taken by a person takes insulin and begins driving should be treated no differently than with diabetes purely for the experience of doing so. When it is a drunk driver if someone is killed. taken to excess it is virtually always But a mistake in insulin dosage alone is not a criminal act. Let’s break an unintended mistake.

Fourth, when a person drives after it down.

First, a person who drinks alcohol overdosing insulin there is still an opportunity to avoid harm—either does not need to drink in order to by testing and avoiding a severe low, survive. Taking insulin in order to or by pulling over when one feels survive and drinking alcohol are symptoms and treating the low before not the same because the reason driving again. Most of us who take for using them is utterly different.

Second, drinking alcohol in certain insulin have reason to believe we can avoid danger while driving. As amounts is always dangerous when a result, we have a legitimate basis driving. Taking insulin by a person to argue that we did not do anything for whom it has been prescribed is criminal if we make a mistake and not. There is a clear difference tragedy occurs. In our experience, between drinking five bottles of we know when we are low and have beer and taking five units of insulin. an opportunity to avoid a serious Both can be dangerous, but only the problem before it becomes a danger. If alcohol is always dangerous when an incident occurs it is an aberration. driving. Safely adjusting insulin

[

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]

Fifth, at the moment of severe hypoglycemia we are not in control of our thoughts and actions. We have no mental capacity to take an intended action. Severe hypoglycemia can sometimes occur in what seems like a virtual flash. A person in this diminished capacity cannot be guilty of a criminal act that requires intent. This is particularly so where that person did nothing intentionally to put him or herself into a state of diminished capacity. The goal was not the feeling that accompanies diminished capacity as it is with someone who drinks to excess. The goal was proper blood glucose management.

These are reasons to distinguish taking insulin from drinking alcohol.

They are also reasons that make a hypoglycemic event that leads to an accident that results in death not criminal in nature. Not murder and not manslaughter. A horrid accident.

But not criminal. Not something that merits time in jail.

Another hypothetical described in the last TCOYD newsletter is about a serious low blood sugar in which the driver does not recognize her symptoms until it is too late and is unable to pull over safely and treat the low before an accident occurs.

I have represented about one hundred people in license suspension hearings over the past ten years, half of whom were involved in an event of this nature. In nearly all cases, no one was injured. But that is fortuitous.

When we go severely low our bodies and minds slow down; we cannot react normally. If we do not pull over before the low becomes severe, an

Question

uestion: I am 26 years old and have been living with

Q

diabetes for 6 years. My doctor recently told me the microalbumin level in my urine is high. Can you please tell me about the microalbumin test and what it means?

of the Month

By Steven Edelman, MD

A

nswer: The first measurable laboratory abnormality in the course of diabetes related kidney disease is the presence of small amounts of albumin in the urine, which is referred to as microalbuminuria. Albumin is a protein that is normally not found at all, or only in very small amounts, in the urine. The prefix micro refers to the amount (small) of albumin in the urine. People with persistent microalbumin in the urine have a higher likelihood of experiencing decreasing kidney function if it is left untreated over a period of years.

Remember that there are no symptoms of kidney disease in the early stages, which is why this yearly screening test is so important. If you have type 1 diabetes, you should be screened for microalbuminuria once a year beginning 5 years from the time of your diagnosis. People with type 2 diabetes should be screened every year from the time of diagnosis. Certain situations, such as strenuous pounding exercise, like running, may make your microalbumin test positive even though you do not have diabetic kidney disease. Hence, confirming the presence of microalbuminuria with at least one or two additional tests is important after a few days without heavy-duty exercise. If it remains positive, strict glucose and blood pressure control, and the use of certain medications such as ACE inhibitors, will be the mainstays of therapy. If you do have persistent microalbuminuria, it is most important to treat it aggressively.

accident is possible at any moment.

When that happens, and someone is killed, a criminal charge will inevitably be considered.

The reasons for the severe low blood sugar, and the actions of the driver prior to the accident, need to be considered with a clear understanding of the medical implications of her actions, and her state of mind at the time, to come to a reasonable determination of the degree of fault involved and whether her actions could reasonably be considered criminal in some form.

No intentional act of murder took place. The driver did not intend to kill someone. Therefore, murder should not be charged.

This does not mean such an event can never be criminal. But more needs to be known about the degree of intent and responsibility before a criminal charge is made.

The third hypothetical presented in the prior issue suggests when a criminal charge might be properly made. In that example, the driver has had many incidents of severe hypoglycemia. The driver clearly has hypoglycemic unawareness—in other words, he does not recognize hypoglycemia in time to avoid it because he does not feel symptoms of these events when they happen. He has had prior events where it happened that were severe and dangerous.

He has been warned about it by his

physician. He does a number of things that set up a severe and dangerous event on this occasion: he takes part in exercise, knowing that this will lower his blood sugar; he then fails to test before driving, despite knowing he does not normally feel symptoms of low blood sugar; he then drives a significant distance without eating.

Does this make him guilty of murder if a tragedy occurs? No. He did not intend the tragic result. Was he reckless and guilty of manslaughter? Perhaps. There are enough bad facts here that a prosecutor would obviously have to consider criminal charges (assuming these facts become (Is It Murder?, continued on page 11)

Taking Control of Your Diabetes 5

LOW

FEELING

Take Control of Hypoglycemia: How to Prevent and Treat Low Blood Glucose ave you ever felt irritable, confused, sweaty, weak, or overly tired? You may have been experiencing symptoms of mild to moderate hypoglycemia, or low blood glucose. Many people are unaware of symptoms and experience hypoglycemia without even realizing it. However, unawareness of symptoms can be extremely dangerous.

Untreated mild to moderate hypoglycemia may lead to severe lows in blood glucose, unconsciousness, diabetic coma, and, in rare situations, death. The good news is that you can be prepared. Education is key—by arming yourself with tools to prevent and treat hypoglycemia, you can take control.

H

What is Hypoglycemia?

Candis M. Morello, Pharm D, CDE, FCSHP, Associate Professor of Clinical Pharmacy at UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, Clinical Pharmacist at VASDHS Christine Luu, First Year Student Pharmacist at UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences.

6 MyTCOYD Newsletter, Vol. 30

Normal blood glucose concentrations, even during fasting, are usually greater than 70 mg/dL. Low blood glucose can be caused by skipping meals, leaving too much time between meals, not eating enough, over or incorrect medication use (especially with insulin), vomiting, diarrhea, vigorous exercise, and excessive alcohol intake. Hypoglycemia can occur at any time, day or night. By regularly monitoring blood glucose, eating nutritious meals, taking the correct doses of medications, and most

importantly, by being aware of the symptoms, hypoglycemic episodes can be minimized.

How Do You Know if You Are Too Low? Symptoms of mild to moderate hypoglycemia may include hunger, irritability, confusion, sweating, palpitations, tiredness, weakness, increased heart rate, nausea, tremors or shakiness, and anxiety. Since catching hypoglycemia early is important, being aware of symptoms is crucial. If ever in doubt about whether or not you are too low, test your blood glucose to confirm hypoglycemia. If you experience hypoglycemic unawareness, testing your blood glucose at regular intervals, and especially before driving is very important.

[

Hypoglycemia can occur at any time, day or night.

]

How Do You Treat Mild to Moderate Hypoglycemia?

Treating hypoglycemia means restoring the glucose in your blood.

You can raise glucose to treat mild to moderate hypoglycemia with an approach called the “Rule of 15.”

1. Test to determine blood glucose is below 70 mg/dL. 2. Eat 15 grams of simple, concentrated carbohydrates (for fast-acting sources, refer to the Table on the next page).

3. Wait 15 minutes.

4. Check blood glucose again.

5. If blood glucose is still below

70 mg/dL, consume an additional 15 grams of carbohydrates.

6. Follow up with a light snack (or with a meal if it is mealtime).

Mild to moderate hypoglycemia can usually be reversed rapidly, within 5-10 minutes. Using the “Rule of 15,” blood glucose concentrations increase quickly and you can avoid over-treating by overeating, which could lead to elevated glucose concentrations and an undesired blood glucose roller coaster. The table below lists 15-gram amounts of effective fast acting carbohydrates including glucose tablets, milk, fruit juice, regular soda, sugar, raisins, hard candies, and glucose gels. Avoid foods that are high in fat, such as pizza, candy bars, or doughnuts, because fatty foods slow the absorption of carbohydrates, making the blood sugar rise take longer.

However, if the only sugary food you have nearby is a candy bar or a doughnut, it is much better than nothing at all. If you experience

a ‘low’ right before mealtime, go ahead and eat your meal without applying the “Rule of 15” as long as the meal you are eating has sufficient carbohydrate to get your blood glucose back up. Contact your healthcare provider if you frequently experience low blood glucose as your medication may need adjusting.

How Do You Treat Severe Hypoglycemia?

Untreated mild to moderate hypoglycemia can lead to severe hypoglycemia and unconsciousness, a situation that cannot be selftreated. It is important to remember that the person experiencing severe hypoglycemia cannot swallow.

Force-feeding food or liquid to an unconscious person can lead to choking. Treatment of severe hypoglycemia requires a glucagon emergency kit, which is available only by prescription. Glucagon is a natural hormone that works quickly to increase blood glucose concentrations. The glucagon mixing and administration instructions may

Fast-Acting Sources of Carbohydrates Source Glucose tablets Glucose gel Fruit snacks Raisins Non-diet soft drink Fruit juice (apple/orange) Milk (non/low fat)

Quantity 3-4 pieces (4 grams per piece) 1 tube of 15 grams carbohydrates 1 package 1 ounce 4 ounces (1/2 cup) 4 ounces (1/2 cup) 8 ounces (1 cup)

be confusing during an emergency.

To prevent confusion in a stressful situation, it is vital to educate people around you (close friends, family, teachers, caregivers) how to prepare and administer glucagon before an actual emergency arises.

Annual reeducation is recommended. Remember to check expiration dates regularly since you do not want to be caught in an emergency with an expired kit.

Although some people go years without needing to use their glucagon emergency kits, it is very important for all patients on insulin therapy to have these kits available and to keep them easily accessible.

Store them in several places such as in the bedroom, a purse, briefcase or backpack, and let the people around you know where the kits are located.

Bottom Line: Prevent and Prepare To take control of hypoglycemia and avoid severe episodes, prevention and being prepared are essential. Be aware of early warning symptoms of hypoglycemia and recognize when you are more likely to go low. Keep fast-acting sources of carbohydrates such as glucose tablets or hard candies in the car or with you when traveling. Mini 4-ounce juice boxes are the perfect size and contain 15 grams of carbohydrates— keep some by the bed as a quick source of glucose at bedtime or in (Feeling Low, continued on page 9)

Taking Control of Your Diabetes 7

Kim Lyons, celebrity fitness trainer of The Biggest Loser gets people moving at TCOYD

By Michele D. Huie

COYD had the chance to chat with Kim Lyons, the face of the new campaign Take the Next Step.

T

Kim, what is the Take the Next Step campaign?

Take the Next Step is an awareness campaign to educate people on how to get active, especially as it relates to nerve pain. The campaign is designed to help people with diabetes recognize the symptoms of painful diabetic peripheral neuropathy (pDPN) and proactively talk to their doctors about incorporating the treatment of pDPN into their overall diabetes care. My involvement includes participating at the Taking Control of Your Diabetes conferences in order to encourage people to pay attention to pDPN symptoms and get active.

active. There are many people who think that they simply can’t exercise, because they are too big or are in too much pain, but I encourage people to start small, just by taking a walk around the block or doing some chair exercises in front of the TV. People are relieved to learn what they can do.

Do you train a lot of people who have diabetes/suffer from pDPN? Prior to working on The Biggest Loser, I trained professional athletes and movie stars so they looked good on the big screen. When I first started on The Biggest Loser, I was outside of my comfort zone. I had to learn all the things that come with being Why did you get involved with obese: the stress on your heart, type 2 this campaign? diabetes, pre-diabetes, neuropathy.

Sadly, there is a lot of disconnect between doctors and personal trainers It was overwhelming, but at the when in fact they should be working same time, so much more rewarding together on patient issues like obesity than getting someone ready for her and diabetic nerve pain. When I was wedding. I was giving someone a new chance on life, and I was totally approached with the opportunity to hooked on the reward. be a spokesperson for Take the Next Step it seemed like a terrific idea Does exercise help because I can really impact people with pDPN? positively. I’ve seen so many benefits YES! Staying that occur when people become active is an

8 MyTCOYD Newsletter, Vol. 30

important part of any diabetes care program. This is especially true if you have a complication like diabetic nerve pain.

It may be hard to keep your blood sugar levels close to the normal range without physical activity. You are likely to develop more nerve damage if your blood sugar levels are elevated over many months or years. Exercise not only helps physically, but helps people mentally and emotionally.

Exercise is about so much more than the physical benefits (which in and of themselves are fabulous!). Exercise releases those feel-good endorphines, and enables people to keep up with their grandkids!

What are some specific exercises that might help with pDPN? My favorite is a leg extension movement that you can do while sitting. Lift one leg at a time, and alternate. Feel the contraction of the muscle, squeezing and then releasing.

I also like creative exercise with arms such as lifing soup cans. There are endless exercises you can do with simple items around the house.

[

“By taking small steps, you might be able to start moving more and get back to doing the things that matter most to you.”

]

them questions, everyone realized what they have in common, and that they understood each other.

Everyone was hungry for information.

What are some tips for incorporating extra physical activity into your daily routines?

These days, we hire someone to do everything for us—from taking care of the garden to washing the car.

We ride escalators, drive everywhere and park as close as possible to our destination. All of these examples are little opportunities for being more active. Get off at the earlier bus stop, park at the far end of the lot, carry a handbasket in the grocery store instead of pushing a cart. And on days when you are really tired, just get in some stretching.

Is there anything that people with pDPN need to do before they start exercising?

See a doctor if you think you may have pDPN because there are treatments available. Any physical activity can help with overall diabetes management. Don’t be intimidated to start small. Let your doctor know you want to exercise.

Find out what limitations you have from a medical standpoint but don’t use those as excuses. If a particular exercise feels good then communicate that to the doctor.

And finally, don’t be afraid to educate yourself.

Feeling Low (continued from page 7) the middle of the night when you are more likely to be both low and groggy.

It is important to know when a low is coming on. Over time, many people tend to get used to their early symptoms, making it easier for those symptoms to go undetected. Some people even lose the sensations completely.

Educate your family or close friends about the symptoms of hypoglycemia so they can help identify low blood glucose in the event that you are unaware of the symptoms or are experiencing confusion. Educate them about the treatment of mild to moderate hypoglycemia and teach them to use emergency glucagon kits in severe situations.

Knowledge is power! Know your blood glucose values by monitoring frequently, be aware of early warning symptoms of hypoglycemia, know how to treat low blood glucose, prepare yourself with fast-acting carbohydrate sources, and teach others about hypoglycemia! By knowing how to prevent lows and by being prepared if they occur, you can definitely be in control of hypoglycemia!

Tell me something about your experience at TCOYD Santa Clara last weekend.

Where can people go for more I had lunch with some people with information on the Take the diabetes and it was interesting to me Next Step campaign? to see that they were eager to learn, www.diabetespainhelp.com but shy to ask about physical activity.

I think as soon as I started to ask

Taking Control of Your Diabetes 9

LET YOUR ENERGY LIFT YOU

THE LETTER I

AN EXCERPT FROM THE ABCS OF LOVING YOURSELF WITH DIABETES” ften in life even when you don’t know how you’re going to accomplish something, you discover that just by having a firm intention, the “how” to get the job done shows up. You see with new eyes, hidden doors seem to open, and solutions appear out of nowhere. Intention is so powerful that just by intending to better control your diabetes, you will.

Why? Because you will naturally take the steps that support this intention.

Invention can also help you with your diabetes management. You can invent yourself anew as someone who manages diabetes well. See yourself in this new role by holding a mental picture of being a diabetes “pro.” See yourself performing your tasks effortlessly. Feel how relaxed and confident you are. You can become better at managing your diabetes by returning to these images often, or simply by taking healthier actions. Either way, you’ll be on the path to becoming a new you.

Now let’s look at the power of illumination. You are illuminated, lit from within, when you realize something. For instance, if you know you don’t test your blood sugar as often as you should, or that you could be doing better with portion

O

10 MyTCOYD Newsletter, Vol. 30

control, allow that truth to burn so brightly that it burns right through all your excuses—and ignites your intention to do better.

Last comes inspiration. Inspiration is a sense of excitement and purpose that comes from the center of your being. Inspiration unleashes your confidence, strength and power to get the job done. To connect with your inspiration, think about what

gives your life meaning and purpose.

Intention, invention, illumination and inspiration are powerful energy forces, and are an intrinsic part of who you are. If you begin to trust them and invest in them, they can help you accomplish magical results beyond your wildest imagination.

R iva Greenberg is the author of 50 Diabetes Myths That Can Ruin Your Life: And the 50 Diabetes Truths That Can Save It and The ABCs Of Loving Yourself With Diabetes. Riva writes for Diabetes Health magazine and has conducted more than 130 interviews with people living with diabetes, family members and diabetes professionals to inform her work and research.

“I was sitting at my first TCOYD event in a workshop called “Coping with Diabetes” when my life changed. The facilitator, CDE and psychologist, Bill Polonsky, looked at the hundred of us sitting there and asked, “How many of you think diabetes is the leading cause of blindness, heart disease, kidney failure and amputation?” We all put our hands in the air. “You’re wrong,” he said, “Poorly controlled diabetes is.” Those few words changed my life. It released me from the worry I had carried for three decades that these complications would be my fate, I realized how I manage my diabetes counts and so I began taking better actions. I’ve heard Bill say that well managed diabetes is the cause of nothing. But here I have to disagree—although, in truth, I think Bill would agree with me—well-managed diabetes is the cause of a healthier and happier life.”

– Riva Greenberg

Is It Murder? (continued from page 5) known to the prosecutor). There are enough innocent facts that the driver might not be guilty of any. He was clearly guilty of negligence, perhaps reckless, blood glucose management.

But negligent or reckless blood glucose management is not the same as negligent or reckless driving.

Hypoglycemia is never intended and can always become dangerous. We know a mistake was made whenever severe hypoglycemia occurs. It is likely that virtually all of us who take insulin have at some time driven while hypoglycemic; just as it is likely that virtually all people who drive have done so at some time while sleepy or distracted or angry—all of which can result in a horrifying accident just as easily as hypoglycemia.

In order to charge someone with criminal behavior there must be some detail that makes the action outrageous; that shows the person was irresponsible and not merely mistaken. Among other things, in a country where so many have insufficient access to medical care; when the standard of care in the medical profession does not call on health care providers to do nearly as much as they should to warn individuals on insulin how to drive safely and avoid accidents; or when health coverage plans do not provide access to tools, such as continuous glucose monitors, that allow people with diabetes to avoid hypoglycemia in the first place, it is unfair to charge someone who was not willful or reckless in causing

A RECENT NOTE SENT

TO

TCOYD

I received your flyer about the conference in San Diego on 10/24/09. I immediately called and described a financialy stressful situation my husband and I are in, but that we have great interest in attending—especially since my husband is a type 2 diabetic and my youngest daughter is a type 1 diabetic. Michelle told me to send in my registration and to send a check for whatever we could afford even if it was just $5. I’ve included $5 for each of us, along with a great big THANK YOU for the generous donors who help to offset these expenses for families who are financially struggling right now.

This is one of hundreds of notes we get at TCOYD about how the offer of scholarships and financial aid enables people to come to TCOYD’s educational and motivating programs. To every family, individual and company that makes it possible for TCOYD to do what we do, a giant thank you from the bottom of our hearts.

If you would like to make a donation, visit SupportTCOYD.org.

TCOYD is a not-for-profit 501(c)3 charitable educational organization. All donations directly support TCOYD, are tax deductible and greatly appreciated.

an accident to be branded a criminal.

This is not to say that those of us on insulin do not have our own responsibilities to know what we are doing and take precautions whenever we drive, but rather, that a mistake is still a mistake even when the consequence of that mistake is tragic. And that such a mistake should not be deemed criminal merely because of an awful result.

Let me add that although I have been involved to some extent in three such cases, these cases are

extremely rare. Drivers with diabetes are not frequently getting in horrid car accidents because of insulin.

However, those of us involved with diabetes must also understand that even one such accident is a horrifying tragedy that cannot be undone. It is up to us to work to avoid it from happening, ever.

– Kriss Halpern, one of TCOYD’s longest serving faculty members, spoke in 2009 at the Milwaukee, Santa Clara and San Diego national conferences on health care reform and its implications for people with diabetes.

Taking Control of Your Diabetes 11

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Doctor Visit (continued from page 2) there are so many other important external influences.

The traditional ways professionals are trained to take care of PWD will not change overnight. As an individual living with diabetes, it is your responsibility to help direct and focus your diabetes doctor visit so that you feel your most pressing problems and concerns have been addressed. On the other hand, you must be careful not to overpower or turn off your caregiver with a barrage of demands and a list of questions that is 10 feet long.

There must be a balance between getting what you truly need and still allowing for what your trained professional needs to accomplish during a typical health care encounter. Let’s all work patiently and persistently together to redefine the diabetes doctor visit.

12 MyTCOYD Newsletter, Vol. 30

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MINDELIVER AND REACHMD LAUNCH DIABETES DISCOURSE HOSTED BY DR. EDELMAN n June, TCOYD’s partner, Mindeliver Media launched the first national radio talk show dedicated to the management of diabetes.

The innovative weekly program airs on ReachMD SiriusXM 160 Satellite Radio specifically targeting health professionals. Dr. Edelman, recently named Educator of the Year by the American Diabetes Association, is the show’s host. Diabetes Discourse features the latest developments in diabetes care, including new

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treatments, exciting research and emerging technologies.

To date, Diabetes Discourse has generated a sizeable following.

Average weekly listeners total 280,000. The program is also available on iPhone. Please visit www.tcoyd.org for more on Diabetes Discourse and information on how to tune in.