Medical

Just a little bionic

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UnknowniPro sensor – 5-day CGM

Noticing I was becoming a sugar-testing junkie recently, I opted to get hooked up to a CGM for a 5 day trial period, save some finger skin and see if I could learn something. 

My recent addiction to knowing where my numbers are, beside a proclivity to perfection, is largely because my blood sugars rise sooo rapidly in the morning. Can I shut the barn door more quickly so I don’t have to do two boluses before breakfast? The first to merely blunt the rise. 

My new CDE put this on me in her office and what should have been a rather simple affair turned out to be quite a painful one. I wasn’t prepared for the tugging, gripping and sensation of tearing skin when this thing went in. In fact you’ll see quite a bit of redness around it which is my blood. My CDE told me it is not uncommon to bleed and not a problem. OK, but it didn’t exactly lift my spirits and it did make me utter, “Diabetes is not exactly a pain-free disease!”

When I left my CDE’s office, newly bionic, I walked about 20 blocks to meet a friend for lunch. Each footfall, I was overly aware of this gizmo dug into my side and the very fact that my walking was impacting my blood sugar. A weird thing for your brain to be so focused on an automatic body function. When I sat down to lunch I copped the banquette seat feeling vulnerable and exposed to any passer by who might ram into my poor abdomen. Well, it’s not really on my abdomen, but I don’t know what you’d call this side area.

Leaving the restaurant I began to experience my plastic gizmo differently. I felt somehow as though it was now my helpmate. As though I was not in this all alone anymore. I found this quite comforting and recognized it as a wholly new feeling.

Now, two days in, I’m used to my CGM, it doesn’t hurt but the five inches of sticky tape that’s holding it in place grips and pulls as I twist and turn. And while my plastic companion is (hopefully) tracking my numbers, so am I four times a day in a log book, along with carb counts and activities, just in case anything goes awry. 

I will keep you posted next week when gizmo comes off. It would be dandy to have learned something more than which pants slide easily over gizmo and which ones don’t.  

The continuing story of my medic alert bracelet

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A few weeks back I mentioned that I read an article in Diabetes Health magazine, Medical ID Bracelets: The $15 Lifesavers that made me realize it was a foolish move on my part not to wear a medic alert bracelet, especially since I have enough lows to warrant it. Granted, I haven’t had a low yet in 37 years I couldn’t remedy myself, but why take chances?

So I did a lot of web searching looking at various bracelets trying to find the right one. One that would say, “Yes, I have a medical condition!!!” if need be, yet be somewhat attractive, in other words not make it look like I was a goner, or be downright ugly. My first choices, could easily be missed as an attractive piece of jewelry, beaded and dangly, pretty, but who would know I needed help? So I settled one from American Medical ID. They have a large selection of bracelets and offer engraving for free and will fit a lot of it on your bracelet as opposed to some other vendors. I chose a sterling silver plaque, $59.95, and I just received it in the mail. It took about three weeks from order to delivery and is engraved on the back with:

T1 Diabetes IDDM

Riva Greenberg, NYC

Call Mom below:

Mom’s phone number

I’m quite pleased with my bracelet so far, it’s small and shiny. My friend who makes jewelry volunteered to make me a lovely chain for it. I think I’ve managed to hit the right balance of “Look, I have a condition that needs care” and an unobtrusive, simple and fine piece of jewelry. The plaque doescome with a free chain or you can select from three chains all priced at $6.

Stay tuned. I’ll show you the whole thing once done. I’m actually looking forward to being able to wear this, and intend to leave it on my wrist once I put it there. 

Do you wear a medic alert bracelet?

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womens-medical-id-braceletsMedical alert plaque from Sticky Jewelry

DiabetesHealth ran an article on its web site last week which got to me, “Medical ID Bracelets: The $15 Lifesavers.” Admittedly, I’ve had diabetes for 37 years, been on insulin for 32 (I was misdiagnosed early and put on oral meds the first 5 years) and have never worn a medical alert bracelet. Why? Thirty years ago when I looked at them, there were few available, they were all ugly and screamed, “I’m deathly ill.” Or so they made me feel. Then I just sort of forgot about them over the years. I learned how to recognize and treat a low, never expect to have a time I can’t, and never received any suggestion from either my general practitioner or endocrinologist that it might be a good idea to wear a medic alert bracelet. When I think about that now, that seems a stunning lack of care.

But reading the article about how such a bracelet can and does save lives, I thought how foolish am I not to wear one. I have enough lows and am alone often enough that I could end up in a situation where I pass out and such a bracelet could save my life. Each morning I walk an hour around my local park. I take my SweeTarts, some money and my keys, but nothing that would alert anyone to the fact that I have diabetes. I do carry a wallet card, but often am out and about without my wallet. Thinking back, my last two great lows both occurred in airports when I was traveling by myself. Luckily I had sugar with me and enough brain cells working to stop and treat myself, but what if I did not….?

So, over the past week I’ve conducted an exhaustive online search to see what’s available, and being the finicky Virgo that I am, have only had trouble choosing because quite a few different styles appeal to me. Although I know I’m in for a bracelet; necklaces bother me and something on your knapsack or some other hidden place defeats the purpose. Also, it’s a bit tricky to find one that both is immediately identifiable as a medic alert bracelet and yet looks attractive enough that you’d wear it. But, too fashionable, and I doubt any paramedic would bother looking to see if there’s life-saving information on your dangly, jewel-crusted bracelet. But feeling these two bracelets satisfy that debate, right now I’m  wavering between the beaded bracelet and more sleek stainless steel lynx bracelet, and then my friend who makes jewelry said, “If you buy an engraved plaque, maybe I can make a fashionable bracelet for it.” Well, now I’m just stumped altogether. But, it’s my plan to have one within a month’s time. I also checked my local drugstores and found you can buy a medic alert bracelet there for about $7.00 but don’t expect any style. 

If, like me, you haven’t thought about getting a medic alert piece of jewelry for decades or no one’s ever suggested you wear one, think again. And if you have access to the internet, expect to find enough choices, whether bracelet, necklace, charms etc, to spend a few hours finding just what you like. Well, that’s if you’re like me, I guess. 

Here’s also what I learned as far as the information to have engraved: 1) Diabetes, 2) If you’re insulin dependent which can be summed up in IDDM (Insulin dependent Diabetes Mellitus) 3) Allergies 4) Phone number to call, and what I actually realize was really important, 5) Your name. And that’s because if you do pass out, those working on you will call your name to try and revive you along with other life-saving medical measures. Since space is limited depending upon what item of jewelry you pick and from which manufacturer, choose the info that’s most important for you. Also, some bracelets will let you engrave on both front and back, others just one side. I’m going with:

Type 1 Diabetes IDDM

Riva Greenberg

Mom: Phone number

It will be interesting to see how I actually feel wearing it after being unencumbered all these years. Will it feel like I’m shackled or a “Badge of Honor.” I’m going for the latter. Will let you know.

Timing insulin, the last installment

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Never mind what you call that!!! How high am I going to go?!

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 The American Diabetes Association advises that postprandial blood glucose shouldn’t exceed 180 mg/dl (plasma value) at two hours after the start of a meal. Personally I find this number exceedingly high and was surprised it was not lowered in their recent January 2009 Standards of Care. Many other diabetes educators I know find it high as well and several other associations and experts believe the two-hour postmeal goal should be less than 140 mg/dl. Whew! Better. 

I’ve placed two posts here in the last two weeks that are excerpts from Hope Warshaw’s (R.D., B.C.-A.D.M., C.D.E.) wonderful article, “Rapid-Acting Insulin
Timing It Just Right.” Diabetes educator and dietitican Warshaw explains how to better time your insulin with your meals to get your post prandial blood sugars where you want them. Among the suggestions are occasionally checking your blood glucose after a meal at hours one, two, and three to help you determine when your blood glucose level peaks and starts to come down again. The overall key to controlling postprandial highs is better timing of rapid-acting insulin. Here are several other useful tips from her article:  

Low glycemic index foods – If your blood glucose is less than 100 mg/dl before a meal and you plan to have a meal with a low glycemic index, wait until you start to eat to take your rapid-acting insulin.

Uncertain carbohydrate intake – If you don’t know how much carbohydrate you will eat at a meal, consider splitting your rapid-acting insulin dose. Take enough insulin before the meal to cover the amount of carbohydrate you are sure you will eat. Then as the meal goes on and you know how much more carbohydrate you will eat, take more insulin to cover that amount. This method is easiest if you are on an insulin pump. (But I can attest that it’s doable even on Multiple Daily Injections)

Drawn-out meals – Pump users who are planning to have a meal that is eaten over time, such as a cocktail party or Thanksgiving dinner or a meal that is higher in fat or lower in glycemic index and high in fiber, (it will slow your glucose rise) may use one of the optional bolus delivery tools on their insulin pump. Most insulin pumps allow you to deliver a bolus over time rather than all at once or to deliver some of the bolus immediately and the rest over the next few hours. People who inject insulin could take half their bolus at the start of a meal and the other half an hour or two later. (I do this and sometimes even inject 3 x as I graze. No it’s not fun but it does help more closely match the correct dose of insulin to what and when you’re actually eating.)

Snacks – Alison Evert, R.D., C.D.E., a diabetes educator at Joslin Diabetes Center at Swedish Hospital in Seattle, advises people to “take rapid-acting insulin with any amount of carbohydrate over 10 grams.” Although it is common to think that a few grams won’t make a big difference, the reality is that 10 grams of carbohydrate can raise many peoples’ blood glucose 30 or more points.

Unused bolus insulin – While the duration of action of rapid-acting insulin is usually given as 3–4 hours, some diabetes experts believe it may continue to lower blood glucose level for as long as 5 hours. You can assume that about 20% of a dose of rapid-acting insulin is used each hour after it is given. In John Walsh’s book Using Insulin and on his Web sitehttp://diabetesnet.com/diabetes_control_tips/bolus_on_board.php, he provides a table that shows insulin activity at 1, 2, 3, 4, and 5 hours after bolus doses of insulin from 1 to 10 units.

When two doses of rapid-acting insulin overlap, their effects overlap, too, and the result can be hypoglycemia. Therefore, when you’re considering the size of a bolus dose of insulin, it is critical that you factor in what Walsh calls “the unused insulin” or “bolus [insulin] on board.” This is the amount of “active” rapid-acting insulin left from a previous injection or bolus dose from a pump that continues to lower your blood glucose.

For instance, before lunch, you take a bolus of rapid-acting insulin. Three hours later you decide to have a snack with 30 grams of carbohydrate. You check your blood glucose and find that it’s high at 195 mg/dl. Assuming 1 unit of insulin for you covers  45 mg/dl, you calculate you’ll need two units of insulin to bring your blood glucose level down to your premeal target of 100 mg/dl and another two units to cover the snack you’re about to eat. You take the insulin, and several hours later, your blood glucose has dropped to 55 mg/dl. Why? Because you didn’t factor in the hour or so of action left from the bolus or injection you took at lunch.

To prevent hypoglycemia from unused insulin, get in the habit of thinking about when you took your last bolus dose and how much (if any) action is still left before taking another bolus to “correct” high blood glucose. Most pumps have a built-in feature that keeps track of how much of a previous bolus dose is still active. For us MDI people we have to log it on paper or in our heads.

Even though I’ve had diabetes for 37 years and injected insulin for 32 (Yes, I’m a type 1 who was misdiagnosed with type 2 and on oral meds the first 5 years) you can always learn something new or refresh what you know. 

Thank you Hope. 

A hospital where patient experience is paramount

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Need a snack? Fruit-only

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The Botanical Garden

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Me and the CEO, Mr. Liak

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Kind reminders to be healthy

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 Can you imagine a hospital where floors are carpeted so you feel calm, soothed and protected? Where doors open silently so as not to jar your jangled nerves? Where vending machines are only filled with fresh fruit and the healthier the meal in the cafeteria the less it costs? How about elevator doors covered in exotic floral motifs and a Diabetes Center where you never wait more than ten minutes to be seen?

I could never have imagined these things but instead I saw them with my own eyes here in Singapore at the Alexandra Hospital. The hospital sits amid a lush and beautiful botanical garden that volunteer employees care for and each floor of the hospital has a view of greenery. In this tropical paradise even medicinal herbs are flowering in the gardens.

This hospital is the vision and result of its CEO, Mr. Liak, and his passionate staff. It is their mission to create a place of healing where people are helped to make healthy choices, even if it’s just taking the stairs instead of the elevator.  No wonder stairways are easily accessible throughout the hospital, not hidden behind impenetrable or locked doors, and they are marked by big wooden red hearts that say, “Please give your heart a lift, use the stairs.”

I had the pleasure to meet Mr. Liak and discuss the state of healthcare in Singapore and the U.S. and the work I am doing bringing a more positive attitude to managing diabetes. Mr. Liak spent three hours with me and my husband, who has worked with him in the past, generously sharing what some would call a contrarian view: give diabetes patients a year of treatment and education and if they improve and own their management, encourage them to be peer-mentors wherein they can give back, help other patients and help the hospital provide its services to more patients. If they don’t take responsibility for their care after a year, patients are free to seek help elsewhere and leave space for new patients at Alexandra Hospital.

To say the least it makes one think. In the U.S. the health care system does not particularly motivate patients to become self-reliant and responsible for their care, and we know this is paramount managing diabetes. In fact, I have heard upon occasion a critical tone from my own endocrinologist’s office when I come in for a yearly visit rather than every three months. But why do I need to come four times a year? I am a well-educated patient managing my diabetes daily and getting the necessary tests as appropriate. I can easily discuss my test results with my doctor over the phone and make any necessary adjustments. I am doing what medical professionals say they want patients to be capable of doing, managing my own diabetes!

After chatting about societal influences on health care and patient behavior, I gave Mr. Liak five copies of my book, The ABCs Of Loving Yourself With Diabetes. His face lit up, he loved it. He said this is what we need, a more cheerful and optimistic attitude about managing diabetes. And with that he toured my husband and I through the hospital halls including what resembled a “war room” filled with storyboards, flow charts and feedback circles reflecting plans for the new, expanded hospital they are building. At every touch-point in the new hospital the patient will be accommodated, from a simple registration process to remote controls where patients can control the light and air temperature of their room. Where room furniture is being built with drawers and countertops that allow patients to put more than one thing in and on them. And who is in the hospital bed photo testing all the equipment? None other than Mr. Liak himself.

Our tour stopped at the Diabetes Centre where I was introduced to the staff and two copies of my book were handed to the Diabetes Centre Director and diabetes nurse. Talk began of translating my book into the Malaysian language, Malay. Thank goodness my head had not grown so large that I could not still get it through the door to the cafeteria where our tour ended. And over a bowl of vegetables and tofu Mr. Liak told me it was a dream of his to employ someone such as myself to consult with his professional staff and help inspire and encourage other patients. Can you imagine? In Singapore, you don’t have to, it’s on the drawing boards.

Leaving Alexandra Hospital I thought if I ever need to be in the hospital maybe I would consider, if time permitted, hopping a flight to Singapore. Meanwhile, I’m happy to do what I can to help the staff and patients here. And now that I’ve finished this post, do what most people who are not in the hospital do in Singapore, shop. 

ADA recommends treating type 2 diabetes more aggressively

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I could be snide and say, “Well, that only took a million years” or I could be thankful and say a lot of patients should now live longer with less complications.

In an article, “New Major Changes in Recommendations for the Treatment of Type 2 Diabetes by ADA and EASD” that appeared in DiabetesInControl, an online newsletter for health professionals, the ADA has issued new recommendations for treating type 2 diabetes more aggressively. 

What motivates the change appears to be the conclusion, “that much of the morbidity associated with long-term microvascular and neuropathic complications can be substantially reduced by interventions that achieve glucose levels close to the non-diabetic range. Although new classes of medications and numerous combinations have been demonstrated to lower glycemia, current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal healthcare status for people with diabetes.”

Translation: Yea, we got new medicines to keep blood sugar in control but most people’s blood sugar still isn’t in control. 

So new ADA health-care providers therapeutic recommendations are to speed the introduction of insulin:

Step 1 — Lifestyle intervention and use of metformin because of its effect on glycemia, absence of weight gain or hypoglycemia, good tolerability profile and relatively low cost. 

Step 2 — Add another medication, either insulin or a sulfonylurea, within 2 to 3 months of starting step 1 or at any time when target hemoglobin A1c level is not achieved or if metformin is contraindicated or poorly tolerated. For patients who have hemoglobin A1c level of more than 8.5% or symptoms secondary to hyperglycemia, insulin is preferred, typically a basal (intermediate- or long-acting) insulin. 

Step 3 — Further adjustments by starting or intensifying insulin therapy with additional injections that might include a short- or rapid-acting insulin given before selected meals to curtail postprandial hyperglycemia. 

David M. Nathan, MD, from the Diabetes Center of Massachusetts General Hospital in Boston says, “The epidemic of type 2 diabetes and the recognition that achieving specific glycemic goals can substantially reduce morbidity, have made the effective treatment of hyperglycemia a top priority.”  Hmmm…it wasn’t before? Oops, there goes my snide side. Hard for a type 1 to fathom the laxity in treating type 2 diabetes. “Maintaining glycemic levels as close to the non-diabetic range as possible,” continued Nathan, “has been demonstrated to have a powerful beneficial effect on diabetes-specific microvascular complications, including retinopathy, nephropathy, and neuropathy, in the setting of type 1 diabetes; in type 2 diabetes, more intensive treatment strategies have likewise been demonstrated to reduce microvascular complications.”

We can only hope physicians will know the new recommendations and patients will get effective treatment. If I were a type 2 I’d ask my health care provider for the best treatment to control my blood sugar to normal levels, whether it’s with a pill or a syringe. For most of us, it’ll mean more years on the planet and spending them happier and healthier.

 

 

Where’s the humanity in our health care?

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Many of us would agree it doesn’t feel like there’s a lot of “care” in Health Care anymore. HMOs, Health Maintenance Organizations, that most of us probably participate in, were set up as cost-saving vehicles not care-giving vehicles;  they work more or less until you really need some kind of care–I can’t get the orthotics my podiatrist says I need, there’s no coverage for anything that might help the tinnitus that drives me mad on certain days and until recently my test strips were so minutely parsed that I could never feel the assurance of testing as I needed.

But I digress. I want to talk about the visit to my ophthamologist yesterday for my annual dilated eye exam. What I observed prompted me to wonder if we need to not just change how Health Care works in this country, but the name itself. Given the power of words, if we renamed “Health Care” to “Humanity Care” for instance would it help remind over burdened doctors who have been mandated to see a ridiculous number of patients within a scant ten to fifteen minutes each day that there are actually human beings inside these objects that get moved like on an assembly line from outer waiting office, to inner waiting office to their sanctuary?

I like my ophthalmologist: she’s bright, wholly competent, invites questions, has a personal and reassuring manner and I am extremely happy I have her in my life since I was made to believe 36 years ago when I got diabetes that I would end up going blind. So, I always feel celebratory leaving her office but I used to also feel comfortable going in, which changed yesterday; I felt a difference in the air, and then on the ground. It was obvious how many more patients needed to be seen, so that everything that was done exhibited that the priority had been given to time management and not to patient care. I observed patients were being treated like objects to be processed; to be moved from point A to point B and then out the door.

First, I noticed extra chairs had been placed in the hallway of the interior office so that every time someone passed, which happened almost every 30 seconds, you had to scrunch your body out of the way or get out of your chair to create more room that wasn’t there, difficult for elderly patients. Then the rush was present everywhere: twice I saw technicians call a patient as they passed by to follow them into an examining room. The first time the technician was gone in a blinding flash around the corner before the patient, well into her seventies, could inch along with her cane. By time she was half way down the hall she shuddered in a slight panic right before me because she’d lost sight of him. The second time it happened, a doctor issued a greeting to a patient, and then when he got to the end of the hallway where his office was turned around to usher her into his room only to see that she hadn’t moved from her seat. He called her again, and she replied in a chirpy, female-wanting-to-please voice, “Oh, I didn’t realize you wanted me to follow you!” laughter. Well why would she, he hadn’t asked her to, he’d just whizzed by.

My own treatment is what made me start notice all this. I was ushered into the first examining room by a technician after I’d sat in the waiting room for over an hour. When the technician closed the door she quickly apologized for the delay, but she didn’t apologize to me, she apologized to her computer since she was facing it and checking the screen for my details as she spoke. In fact, everything she said that was meant for me she said to her computer, her notebook or her equipment. Was I meant to feel sincerity in this communication?

Just the night before I’d seen a segment on the news show, 60 minutes, where a British adverturer in his 70s, who began a business to fly doctors, equipment and medicine to third world countries is now doing it almost exclusively in impoverished areas of America. His flying doctors, dentists, eye doctors, nurses take over a hall for a weekend in West Virginia, Kentucky, Washington and see about 800 patients over the weekend, sadly having to turn away hundreds for lack of time, personnel and equipment. A man was there who’d had an abcess tooth for more than two years which pained him every day. Young women were there who got a cancer diagnosis that day and the name of a nearby clinic. Yet the story that made me cry was of a petite, slim woman in her seventies, frail and cheerful who’d been one of the ones turned away and still she was cheerful until by a small tender act the journalist interviewing her ushered her to an eye doctor who made an extra few minutes to attend to her. She’s been wearing the same glasses for the last 16 years out of which she has not been able to see properly for years, yet she can’t afford to go to an eye doctor. She has no insurance because she can’t afford it after a lifetime of working. When she thought she’d be turned away she expressed that it was alright, she’d manage somehow, she had some friends and support in her church group, yet her face told another story of disappointment and our working poor. When asked if she asks her friends or church group to help her, she responded she didn’t want to be a burden, and the journalist reassured her there was no shame in asking for help, and she burst into tears. Watching this I began to cry for this frail, poor woman who’s worked her whole life and now can’t even afford an eye exam and a pair of glasses–here, in one of the wealthiest nations in the world.

If we started hearing on every news station what an awful state “Humanity Care” is in these days and reading about how poorly run our “Humanity Care”is instead of “Health Care,” maybe we’d at least be reminded that we’re actually talking about people, not cattle, not objects, not numbers. Can two words change how we think? Hmmm….”Humanity Care,” it’s beginning to grow on me.

A weak tendon can hurt your heart

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I almost had a meltdown in my podiatrist’s office this morning. Dratty, ratty tears ready to spring forth as he sliced into me with his diagnosis. Yes, yes I know I have tendonopathy, an MRI told me so last week. After an hour in that MRI machine the report said “weakness in ankle tendon” more of less. But it wasn’t that knowledge that cut, it was the reason my doc presumes I have this weakness. As he said, “Well, if we look at the possible causes,” and mind you I really like this doctor, “there’s aging and foot structure, and of course your diabetes.” Ding, ding, ding. 

There it was – again, and again, and again it rears it’s ugly little head. My foot prescription is another two weeks in the boot and then an ankle brace and physical therapy. But where’s the prescription for my aching heart? Walking is my salvation and solution; I rely on it to stay as healthy as I am. The chance that I can’t continue my power-walks cuts like a knife, as does the knowledge that as good as I am, as great as my diet is, as remarkable as my A1cs are in the 5s, no matter how hard I try to keep the numbers all in line, diabetes can cause anything any day. Including meltdowns no matter how swell I live with it most of the time. 

The answer? I told my podiatrist, “Next time I see you if I ask again what caused my ankle problem, you are not allowed to mention the d-word. You must tell me aging is the culprit. I don’t mind that since everyone I know is aging. We had a laugh and he got, I mean really got how telling a patient fairly casually that their diabetes might be the cause of something can be highly emotionally loaded. So maybe I used my “teach one person about diabetes” command from Tuesday’s Diabetes Alert Day today. 

Just to let you know tomorrow I fly to Spokane, Washington to deliver the A1c Champion presentation at Rockwood Clinic where 1,000 people are expected. Then for me it’s play-time in San Fran. This blog will go quiet for about 10 days.

Happy Insulin Day!

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UnknownFrederick Banting

Did you know that on this date — October 30 in 1920, Frederick Banting woke from his sleep and wrote down the method to isolate insulin? Don’t worry, I didn’t know either. A friend, who is an M.D., just sent this salutation to me in an email and it gave me a moment’s pause. Banting’s dreamed method was so on the mark that in January of 1922 he treated the first patient with type 1 diabetes successfully! In that regard I am very happy to wish you a fabulous insulin day.

Think today how lucky you are. Millions died from diabetes before insulin was discovered and had to subsist on starvation diets before their grizzly end. So, maybe on Happy Insulin Day we should all celebrate by indulging in a favorite food — pizza, Drake’s coffee cakes, cherry pie, mocha fudge ice cream (oops, my fantasies) — because we know we can manage it with insulin. And, yes, tomorrow is another day.