The high cost of priming (insulin pens)


Unknown.jpeg The cost of insulin has skyrocketed in the past several years. But there’s another costly wastage no one is talking about. And that’s the two units of insulin you shoot into the air to prime your insulin pen. More about this below.

Regards the cost of insulin we blame Pharma who blame PBMs Pharmacy Benefits Managers. From what I can make of it they’re the middle men, and women, who are part of the cost determination for drugs and which drugs get on your health insurer’s formulary. If your drug isn’t on it, you’ll pay a significant premium to continue to use it, or be forced to switch from what your doctor recommends to what your health insurance covers.

Making a life and death drug like insulin unaffordable for large groups of people is criminal in my eyes. And then it occurred to me, when I was generously given an inpen, that the priming wastage that occurs using an insulin pen is also criminal.

I was eager to try the inpen because it’s a digital pen that keeps track of a number of dosing markers including when you took your last shot, how much you took and how much insulin you still have onboard. But when I’d prime the pen, sending two units of insulin into the air, poof, gone, for my one unit injection, I couldn’t do it. I used the pen a week and then sacrificed being sure whether I’d taken my meal time shot for conservation. My Jewish, Virgo practicality just couldn’t let me waste more insulin than I was using. And then I got mad.

If you have type 2 diabetes and dose 40, 60, 80 units for a meal or a day, maybe two units/injection doesn’t seem like a big deal. But you’re still being robbed of probably six to ten units a day. If you have type 1 diabetes like me, and eat a low carb diet, you may only be taking five or six units a day. I take one unit typically to cover a low carb meal. Taking five units of mealtime insulin a day would cost me an additional five to ten units for priming (I typically prime with one unit, sometimes I need two).

I use a Tresiba pen for my basal injection. I take six units of Tresiba every morning. Tresiba is only available in a pen so I waste the priming unit or two. I have no choice. For my bolus, either Fiasp or Humalog insulin, I draw my dose up with a syringe from an insulin pen cartridge. No priming involved. I specifically use a pen cartridge not a vial or I’d be throwing two-thirds of a vial of insulin away at the end of every month.

I don’t know if this wastage was purposely built into the design of insulin pens but I find it hard to believe we can’t create an insulin pen, or similar delivery device, where taking our insulin doesn’t cost us more than the insulin we use.

I’m also surprised I’ve never heard anyone talk about this wastage or bring this matter to the attention of pen manufacturers seeking a solution. I’m curious what you think.

Joint collaboration of Lions Clubs International and the IDF recognized at the United Nations


The Lions Clubs International, the largest volunteer, service organization with clubs around the world, held their 41st annual meeting at the United Nations. Throughout the day, they updated members on missions and accomplishments. They have done tremendous work in detecting and treating eye disease in children, in childhood cancer, disaster relief, eradicating hunger and poverty and more.

They have also put a spotlight on diabetes through a joint collaboration with the International Diabetes Federation. An association of 230 diabetes organizations from 160 countries. There is a Memorandum of Understanding between the two organizations to raise awareness of diabetes, make screening more available, as well as education and access to care. It was my honor to be the face and voice of this collaboration, as a member of IDF’s patient advocate group, the Blue Circle Voices.

Highlights: I shared the stats – 425 million people around the world have diabetes. One in three U.S. adults have diabetes or pre-diabetes, and 9 out of 10 people with pre-diabetes don’t know they have it.

Diabetes is not just a matter of insulin resistance (type 2) or not producing insulin (type 1) but also a condition that affects people emotionally: shame, guilt, frustration, fear, stigma.

I shared a service project that took place in Costa Rica last month. A young woman with type 1 diabetes, who’s a psychologist, Daniela Rojas, ran a 3-day adventure camp for children with type 1 diabetes. After every physical feat the kids read an inspirational essay from my book, The ABCs Of Loving Yourself With Diabetes, (Spanish version, El ABC para aprender a quererte teniendo diabetes), that became an open window for them to express and share feelings and fears they never had before. And to realize they are strong outside, and in. This camp is a replicable model of excellence for diabetes camps around the world. I heard throughout the day Lions’ interest in working with diabetes camps.

I received applause when I announced I’ve already applied for my Joslin 50-year medal still three years away, and laughter when I asked if my unruly mane of hair might make me an honorary Lion, well Lioness.

I closed with a story of my father, who when I lay in my hospital bed 47 years ago upon diagnosis, shouted at my cold doctor, “There’s a person in that bed, not just a disease!” Maybe that’s why today I share with health professionals a way to put “Heart-Ware,” the seeing of each other, back into health care.

Above all, I was thrust back into a time when people came together just to do good. Maybe it never left but it’s hard to feel when we are so divided as a nation, as a world. The day was a refreshing and reassuring confirmation that kindness still lives in people’s hearts. And that activism to help one’s neighbor is occurring every day, in small and large communities, through the work of passionate Lions, Leos, Lionesses and Blue Circle Voice members.


My fellow diabetes advocate and friend Christel Marchand Aprigliano was recognized by newly appointed Lions Clubs International President, Gudrun Yngvadottir (from Iceland), for her amazing work influencing diabetes government policy. Rock on Christel! And rock on Gudrun who, having injured herself while skiing a few weeks ago, wasn’t going to miss the auspicious day.


Marking 47 years with type 1 diabetes

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The diagnosis came February 1972 when I was 18. Spent 4 days in the hospital then went back to college, away from home, with insulin vials and syringes. Didn’t know much more than, “Don’t eat candy bars.” That was my diabetic diet. How far we’ve come.

Many call the date of their diagnosis their “Diaversary.” I call it, “Wow, what the f+&k! How amazing I’ve actually gotten this far!” If I had a bedpost, I’d add another nick to my notches for another year gained.

So far I’ve gotten here with few complications – diabetes complications. I have slow-growing cataracts (about 15 years growing), the occasional tingling in my calves (immediately helped by alpha lipoid acid, get it at the health food store), some hearing loss (not usually talked about in diabetes), but nothing much else I can think of. Don’t ask about the everyday decision-making complications. They never end.

I filed for my 50 year Joslin medal five years ago when I wrote this piece for the Hufington Post. The woman who runs the program encouraged me to do so. So, if you’re anywhere near the 50 year mark, why not get your entry in?

I don’t know where the husband is taking me to celebrate in 2022, but I realize this is a big one. Maybe crystal clear water and drinks with umbrellas, and nothing less, should mark this occasion. FIFTY YEARS WITH TYPE 1 DIABETES! Of course I’m thrilled to know Joslin now gives medals for 80 years!

Musing now, I recall something from when it all began. I was in the hospital while they were getting my blood sugar down. My hospital doc was so cold. He told me all the complications I was going to get and gave me two books to read about them. My father, having had enough of his attitude yelled at him, “Don’t you realize there’s a person in that body?” Thank you dad. Thank you dad. Thank you dad. Maybe that’s why 32 years later, I started working in the emotional aspect of living with diabetes.

So look up when you mark another year with diabetes. Stop, take a moment, and congratulate yourself for still being here. Screen Shot 2016-07-16 at 9.09.18 AM.png

The shaming language of diabetes

There’s a movement afoot, that began last year, by the American Diabetes Association, American Association of Diabetes Educators and a number of patient advocates. The aim: to change the shaming, blaming language about people who have diabetes. My friend, warrior CDE, RN, College Prof, Diabetes Educator of the Year, and type 1 herself, is carrying the torch.

Read the full article at ThriveGlobal.


Keto & IF – and no more emotional eating


Unknown.jpeg There’s a lot on the internet about the advantages of eating a high fat, low carb ketogenic diet. Most will say it works best when you’re doing intermittent fasting. I agree. I’ve been doing both for the past month.

I realized in addition to the health, weight loss, reduction of inflammation, metabolic syndrome busting effects, hair growth on your Uncle Larry’s head (sadly not true, but keto does fix a lot) there is a striking advantage I’ve never read about. I experienced it yesterday during my frustrating, miserable day.

I was a sad sack due to an accumulation of things, mostly having to do with a broken toe that still has me barely limping in a surgical shoe. That broken toe has made me a prisoner in my apartment; I’ve been feeling isolated. Not good for happy social hormones. I reviewed all my family members’ problems and felt overwhelmed by the abundance of Medicare papers I have to read. I also watched the Michael Moore movie, Fahrenheit 11/9. That got me entirely depressed. Then let’s not forget there’s always managing blood sugar on top of that. The sky was dark grey and so was my mood.

Yet – and here’s where the revelation comes in – I didn’t get any urge to eat! We’re always told we don’t just eat out of hunger, but when we’re sad, lonely, happy, celebrating, anxious, bored.  I was half those things combined, yet had no craving, no hunger, none of it. And trust me, I was always someone who would reach for food as solace, not lose my appetite to grief.

I realized that ketogenic eating and intermittent fasting doesn’t just stop cravings and lower appetite (because your hunger is satiated from fat, not spiked by carbs and you’ve likely worked your way out of your Leptin Resistance), but those benefits are with you during times of emotional stress too. Woo Hoo!

Disclaimer: I am not a medical professional, dietitian or clairvoyant. I have lived with type 1 diabetes for (47 years in two weeks) dieted for years when I was younger, and have recently been experimenting on myself with high fat/low carb eating and fasting.

“That Sugar Film” – and two ways to stop sweet cravings



I sent my friend, Karen Rose Tank, fellow type 1, The Suppers Programs leader (group cooking skills class and socializing) and health coach, a link to a film I think everyone should see – That Sugar Film.

Produced in Australia by fit and healthy Damon Gameau, Damon takes us with him as he eats anew for 60 days. He leaves behind his healthy low-sugar, low refined carb diet to eat like most of his fellow Aussies – an over the top refined carb, unhealthy fat diet. A diet most Westerners eat.

Damon’s goal was to consume the amount of sugar his mates do – 40 teaspoons a day. To make it more interesting, Damon will get those 40 teaspoons of sugar not from obvious offenders: cake, cookies and ice cream but from foods touted to us as healthy:  breakfast cereals, fruit yogurts, smoothies, granola bars, juice. Foods that say on the front of the package, “Heart Healthy,” “All natural,” “Fortified,” “Low-fat.”

Beside being sick to his stomach the first few days, and feeling euphoric when the sugar hits his bloodstream only to crash a few hours later, all of Damon’s metabolic markers change. He gains significant weight, almost all in the form of dangerous belly fat. In just 60 days he has fatty liver disease. His blood sugar elevates him into the pre-diabetic range and he raises his risk factors for hypertension and cardiovascular disease.

Experiment completed, Damon returns to his former low carb, high healthy fat diet, loses the excess weight and all his disease markers return to normal.

Karen told me the night before I sent her the link to the movie, she’d gone to a conference and been “good as gold.” She ate the sandwich they served without the bread, skipped the cookies for an apple, but….after passing the plate of cookies three times … she took two cookies off the platter. The first was delicious and she enjoyed it, the second she ate even though it tasted sickening. Her blood sugar spiked overnight and the next morning she was beating herself up for eating cookies. As we are all capable of doing.

But the next morning Karen did something. She made the sign at the top of this post and hung it on her refrigerator. The day after, she embellished her sign, not just citing the action she wanted to cease, but affirmations of self-love and actions that keep her relaxed and healthy. That sign is below:


Now, admittedly, you need a fairly tolerant family to let you hang this, but reminders are often helpful. I thank Karen for letting me post these here and in our busy, crazy lives, seeing visual reminders of support are often very helpful.

Replacements are also known to be helpful and that’s where I offer you a second red light for sweet cravings:


When my mind is rummaging for what sweet I can eat, I open the fridge and reach instead for a pickle or olive. Trust me, when that salt hits my tongue, my sweet craving is done.

I broke my toe, I’m barely moving, I’ve lost three pounds, I’m not hungry, my blood sugar’s in range. What’s happening?


While I’m typing this my right foot is in a surgical shoe. New Year’s Day I broke a bone in my toe and badly bruised my foot. For those who want the gory details: the husband and I were sleeping at my mother’s house and I had moved a small bookcase out of the bedroom to make more space. I ran smack into the corner of it with my foot the next morning in the dark.  Stars? Yea, I saw them.

These past three weeks I’ve not moved more, or more quickly, than this slug above. I’m spending an inordinate amount of time, literally, lying around. On my back, on my side, on my bed, on the couch, watching videos, binge watching the fantastic Scott & Bailey and being my inner slug.

When I do go outside, I put my bad foot forward and drag my other foot behind. Think Tim Conway on the old Carol Burnett show. I have a six block radius I can cover to get essentials. Then it’s back to the bed, couch, wherever immobility is welcome.

I will recover. In three to five weeks. But this morning I was reflecting on how this has turned into an unexpected experiment about exercise, weight and diet. And while I’ve been a believer these past few years in the health benefits of keto (ketogenic diet) and intermittent fasting (IF), my beliefs have only been confirmed.

This is what I’ve experienced:

  1. Regular daily exercise has little to no impact on weight. I’ve lost three pounds with opening and closing my eyes being one of my most arduous activities.
  2. I’ve been doing 16 hour intermittent fasting since I broke my toe. I don’t eat after dinner, unless I need something to raise my blood sugar before bed. The next morning I have a cup of coffee with half and half and don’t eat until lunch at noon or 1 PM. I’m also eating what I call a modified version of keto: a very low refined carb, (vegetables are carbs but not refined carbs) moderate protein, moderate healthy fat diet. This is the lowest weight I’ve been as an adult since I was in my twenties one day. I think it was a Tuesday.
  3. The intermittent fasting and keto has lowered my appetite hormone, gherlin, and raised my satiety hormone, leptin. I’m watching tons of videos on YouTube about keto, IF, insulin resistance, metabolic syndrome, cardiovascular disease and diet and none have stimulated my appetite.
  4. The Dawn Phenomena. Normally I take 1 unit of rapid acting insulin when I wake to counteract the rise in my blood sugar. In the early morning hours the liver  throws glucose out into the blood stream to get you ready for activity and cortisol rises. These days my biggest activity after checking my rising blood sugar is going back to iPad (yes, now a verb) on my bed. 1 unit is too much. I’m guessing my liver, noticing there is sparse activity after I wake, is throwing less glucose into my blood stream. And, on this way of eating my blood sugar stays in range 95% of the time.
  5. My energy has not wavered. Committed one hour a day walker that I am, I feel no more or less tired being a slug.

Sure this is an N of 1. This is just me. What’s happening to me now. Still, these are interesting discoveries. The insight that exercise really does not impact weight (although I do agree it’s healthy and helps you maintain your weight) and that IF and keto really take weight off quickly and easily.

These are the keto, intermittent fasting, LCHF (low carb high fat eating which is my keto style) gurus I’ve been watching and reading:

Dr. Jason Fung – nephrologist and IF advocate

Dr. Robert Lustig – UCSF Professor, advocate in getting rid of processed foods, expert in weight, metabolism and diabetes

Michael Pollan – investigative journalist, author of several books including Food Rules

Nina Teicholz – investigative journalist, author of The Big Fat Surprise

Gary Taubes – investigative journalist author of several books including Good Calories, Bad Calories

Ivor Cummins and Dave Feldman – engineers who’ve cracked IR and the bad cholesterol myth

Dr. Eric Berg – tons of videos on YouTube about keto, IF, diabetes, metabolic syndrome. Short, simple and old fashioned teacher style, markers on a white board

Dr. Mark Hyman – Director of Functional Medicine, Cleveland Clinic. This is a great interview series.

An interview between Ivor Cummins and Eric Berg on insulin resistance, diet, diabetes and how we’ve all been nutritionally duped:

And a fascinating video on how IR, the elephant in the room, and metabolic syndrome drive cardiovascular disease and what to do about it:


It’s Insulin Resistance, not cholesterol, that causes most degenerative diseases


If you doubt this watch a few of Dr. Eric Berg’s videos on YouTube. He’s an expert on the ketogenic diet and intermittent fasting. He explains, simply, why it’s Insulin Resistance that creates diabetes, obesity, fatty liver and heart disease, most degenerative diseases.

Having just stumbled across him, it was a coincidence that a friend this morning sent me an email to say his wife was researching foods low in cholesterol to create a healthier diet for them. I wrote this response immediately and figured this is information I should share:

The great majority of our cholesterol is made by the body, not consumed from food. Dietary cholesterol has little impact on us. And, it is a common myth that cholesterol is the culprit of heart disease. Rather than cause obstructions in our arteries, cholesterol shows up like an ambulance, when irritation occurs, to fix it. It’s been shown through scientific studies over decades that just as many people get heart attacks as have low cholesterol as high.

Cholesterol is only threatening when it’s oxidized. Oxidized cholesterol is called Remnant cholesterol. You calculate your remnant cholesterol by adding up your LDL and HDL and subtracting the number from your total cholesterol. If the number is less than 17 that’s optimal. Increasingly higher numbers are less so.

But cholesterol is only a minor player. The real offender is a diet of too much sugar and starch causing too much insulin in the bloodstream. Every time you eat carbs (and there are carbs in almost everything including vegetables, but not in fat), insulin is released to ferry the breakdown of that food or beverage, which is now glucose, from the bloodstream into the cells. Due to our highly refined carb diet, and frequent snacking, extra insulin is being called forth multiple times a day. We begin to develop a state of insulin resistance (IR): either 1) You can’t produce enough insulin for your constant carb consumption and/ or 2) You’re gaining weight (the two go hand in hand) and belly fat blocks the action of insulin. This inefficient use of insulin is what causes obesity, type 2 diabetes, heart disease and brain diseases like dementia and Alzheimer’s – also known as Type 3 diabetes.

Let’s unpack that a little more. Insulin is a fat storage hormone. When it drives sugar (glucose) into the cells from the blood, the glucose gets stored as fat for future energy use.  With the constant consumption of carbs, our bodies run on these for energy and never get to use our stored fat. Insulin being a fat storage hormone, we start gaining weight. As we gain weight, this fat accumulation around our middle further impedes  insulin’s action. Now the body has to push out more insulin to keep blood sugar levels from rising above normal. This typically goes on for years before the body can no longer push out enough insulin and blood sugars noticeably rise. Wham, type 2 diabetes!

The common theory is people get type 2 diabetes because they’re fat. The alternate, and widely growing, theory is people don’t get diabetes because they’re fat. They get fat from years of insulin resistance (IR) due to our heavy carb diet.

Another way to say this: With our highly processed, carb heavy American diet, our body pushes out greater and greater amounts of insulin to drive the sugar into cells where it gets stored (as fat) for later energy use and keep blood sugar in normal range. As the cells reach capacity to hold the fat, insulin drives the sugar into and around vital organs. This happens for years until the maximum amount of insulin the body can produce no longer is enough. Then, after years of insulin resistance you see on your blood test a higher than normal blood sugar level and you’re told you have type 2 diabetes. Most people will also have signs of a fatty liver and the beginning of heart disease.

Most people with type 2 diabetes are started on pills to lower their blood sugar. But the IR has not been resolved. When the pills no longer work  they are put on insulin to keep their blood sugar down. Now they have extremely excessive amounts of insulin circulating in their bloodstream. This drives their blood sugar down, but makes the IR worse, makes the fat accumulation worse, creates more weight gain and fat in and around the organs until the person dies of a heart attack or gets dementia.

So why is IR going unaddressed? Your treating practitioners have been taught diabetes is a condition of high blood sugar, not a condition of insulin resistance. Their focus is to lower the blood sugar, and so the cause, the IR, remains.

It is important to lower high blood sugar, but what’s needed is to work on reducing insulin resistance: address the cause. This can only be done by eating less carbs so less insulin is needed. When insulin levels fall, weight comes off and the body begins to normalize its blood sugar. Sugar, not fat, insulin, not cholesterol, are responsible for 2 out of 3 people having diseases grouped under diabesity – diabetes, high blood pressure, heart disease, dementia and Alzheimer’s, among others.

This brings us back to the ketogenic diet that is gaining so much popularity. Keto is a very low carb (and so will reduce insulin), moderate protein and high healthy fat diet. People lose weight and  many people are able to reverse their diabetes. I do a modified version of keto.

Intermittent fasting (IF), is often linked with keto as a form of switching the body from burning carbs to burning fat. Like its name, IF means you go longer periods of time without eating. You might fast between finishing dinner around 8 PM and eating lunch the next day. You could not eat for 24 hours or do a fast of several days. IF also significantly drops insulin levels and people lose weight and many reverse their type 2 diabetes. Dr. Jason Fung, is a leading expert in the field.

Just as we’ve heard,  genetics load the gun, but it’s the environment, largely diet, that pulls the trigger. If this speaks to you, do your own research. There’s lots of information online regarding all these topics above.

“Diabetic” foods for being stranded on a desert island should you ever be


First I hate the word “diabetic” proceeding anything, but hey, I use it here to be able to say that. Second, there’s nothing special about food for people with diabetes. I never eat low sugar or low fat anything. I eat healthy real food that has little to no sugar and healthy fat.

When I used to answer that childhood question – “If you were stranded on a desert island and could only have a few things to eat what would they be?” I would have told you Greek plain yogurt and peanut butter. I could never understand why of all the things they put in yogurt today, peanut butter is still glaringly not one of them.

These days, however, I would slightly amend that request. I’d want what I typically eat for breakfast when I’m not intermittent fasting. I’d want Brown Cow plain yogurt with its incredible creamy top (like the cream that floats to the top of fresh milk) and almond butter (inexpensively purchased from Costco) and tahini (pulverized sesame seeds) which I get from the middle eastern store 1.5 miles away from my home. But I think it can be found in most supermarkets.

I do add some nuts but I’ll skip the nuts since I don’t want to tax whoever is being kind enough to give me some food on this desolate desert island I have somehow found myself on.


These days if I could ask for one more edible it would be chia seed pudding. Of course it’s one food, but does have several ingredients as you can see above: a can of full fat coconut milk, chia seeds, liquid stevia, unsweetened cocoa powder and cinnamon. I mistakenly left the vanilla out of the picture. I mix it all in that yellow pint-sized container and voila in about an hour in the fridge it’s pudding.

My chia recipe – It really doesn’t get much easier. Fill the container with as much coconut milk as it will hold, most, but not all of this 13.5 oz can, add 4 or 5 tbs of chia seeds. I like 4 so the pudding is not so thick, a few drops of stevia depending how sweet you like it, a teaspoon of vanilla and a handful of blueberries. Today they came out of my freezer. The cocoa powder and cinnamon are optional.

Of course you can really play around with what you add after the coconut milk and chia seeds. Add nuts, different fruits, sometimes I cut a dried prune into the mix. Some people replace the coconut milk with almond or soy milk but I feel the coconut milk has particularly healthy benefits as a short chain fatty acid whatever, whatever… The chia seeds are high in omega 3 antioxidants and fiber, you get anti inflammatory benefits from the cocoa powder and cinnamon seems be a wonder drug with many benefits ascribed to it including lowering blood sugar (which I can’t say I’ve ever noticed) and reduced risk of heart disease.

Now, you do deserve a prettier picture of the pudding than I’ve supplied above along with recipe variations —