A type 1 support group for women in New York City

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A support group for women ages 18 to 35

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 The other night I met with a young woman, Katie, at a tea shop in lower Manhattan. She’s a social work student and has single-handedly put together a type 1 support group of young women, a rarity in New York City. They meet at the Friedman Diabetes Institute at Beth Israel Hospital (317 E. 17th Street) every second and fourth Tuesday of the month from 6-7:30 PM. If interested, you can contact Katie at: DiabetesNYC@gmail.com. I was meeting Katie because she was interested in my coming to speak to the group.

On the subway ride to the tea shop I thought of the several things I could talk about. I could talk about the principles in my book, The ABCs Of Loving Yourself With Diabetes. About how if we focus on the good things in life like love and friendship, think back to how we’ve overcome obstacles in the past and call upon these same strengths dealing with our diabetes, and be kinder to ourselves as we try to manage this slippery slope of blood sugar numbers, that we will be more capable to manage our diabetes.

I thought about my book that will be on bookshelves this summer, 50 Diabetes Myths That Can Ruin Your Life: And the 50 Diabetes Truths That Can Save It and that I could talk about the most common myths that even well educated patients believe, and clear up the confusion. Now that would be a lively discussion!

I arrived five minutes early to the little Greenwich Village outpost and after surveying the more than 50 varieties of tea took a seat at a small table in the front of the shop. Katie walked in right on time and fit her self-description: black coat, dark curly hair, red messenger bag. We greeted each other and after bringing back our pot of tea began to talk. When I asked Katie, “Is there anything in particular you’d like me to talk about?” She said, “Yes, could you talk about relationships?” Relationships? Me? And so I asked, “Relationships? Me?”

She said, “I read your article, Love and the Juvenile Diabetic and it really touched me, and our members being young women are really concerned about dating and boyfriends, like how do you tell someone you’re dating you have diabetes and when do you tell? Relationships is on the top of nearly everyone’s list.” Wow, I thought, being happily married for the past seven and a half years has wiped out my memory. For surely I felt that way in my 20s and 30s. I told Katie I could share my own experience, but I had no credentials to talk any more expertly about what her young women should or shouldn’t do, only common sense like, feel your way, trust your gut, tell your partner what he or she can do that would be of help to you and if they ignore your needs, run, run, run in the opposite direction.

Thinking about it on the train home I began warming to the topic more and more. When I told my husband what Katie wants me to talk about he said, “Maybe I should come too and represent the other half.” Well, we’ll see, we’re letting the women vote on that.   

So maybe now I’ll be able to add a new line to my bio: the Carrie Bradshaw of diabetes relationships. In case you’ve forgotten, Carrie Bradshaw was Sarah Jessica Parker’s lovable relationships columnist on the HBO sitcom/drama “Sex and the City.”


 

 

A day without halvah is like a day without sunshine

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UnknownHalvah, Tahini-based sweet

Yesterday I had a friend over for lunch. A friend who grew up in Mississippi, lives in Texas, and with whom I’m touring for a week in late April her home state. I thought since she will shortly introduce me to hush puppies, cheese grits, biscuits n’ gravy and chicken fried steak, oh, my god… (And yes, we are both diabetic and will have to test, test, test and walk a lot), I thought I’d introduce her to one of my favorite sweets that I was sure she’d never come across–halvah. Have you?

Like the 1979 advertising campaign,“You Don’t Have To Be Jewish To Love Levy’s Jewish Rye” you don’t have to be Jewish to love halvah, but if you’re not, nor of middle-eastern descent, you may never have tasted it. 

Halvah is a sweet that has a texture as described by my Mississippi friend, this way, “Boy, that just melts in your mouth!” It comes in vanilla, chocolate, plain and/or with nuts. My personal preference is marble with nuts. The common ingredients are: tahini (sesame seed paste), sugar or honey, water and sesame oil. 

The Shocking Nutrition Facts:

1 bar (8 oz)

Total Fat: 66 g

Saturated Fat: 11g (the “unhealthy” fat)

Polyunsaturated Fat: 30 

Monounsaturated Fat: 21 g

Total Carbohydrate: 128 g

Dietary Fiber: 10 g

Protein: 23 g

Mind you to eat one bar for me would be unconscionable. You can also find low fat, low sugar halvah in some specialty stores, but it’s not easy to find and frankly, it doesn’t taste half as good. I say eat the real thing in small portions. I buy it at a middle eastern shop where it’s sold in chunks off a huge mound, think of a big wheel of cheese. My eating directions: Cut a small sliver (very thin slice, likely half an ounce), pop into mouth and savor. Cut one more sliver and repeat. Wrap halvah and put back into the refrigerator before you eat the whole thing.

When my friend’s step-daughter came to pick her up, she knew what halvah was and went right for it. So of course I packed it up for them to take with them on their trip home. But, I just happen to have bought another package yesterday. 

Want to live a long life with diabetes? Be positive and dance!

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Unknown

In the fall 2008 Countdown magazine, {the quarterly magazine of the Juvenile Diabetes Research Foundation} I found the article, “Research for Life.” The article is about whether people who’ve had type 1 diabetes for many years still have any insulin producing beta-cell function. If they do the hope is it can be a means for regenerating their insulin-producing capacity and curing themselves of diabetes.

I’ve been familiar with this line of research for some time but something in particular in this article caught my eye. That is that researchers discovered among the type 1s who had participated in the Medalist Program at Joslin Diabetes Center, (type 1s who’ve had diabetes for 25, 50 and even 75 years and received an honorary medal), the presence of complications did not correlate with typical risk factors for complications such as — how long you’ve had diabetes, your insulin production or even A1c levels. About 40% of the medalists did not have any serious complications, even after 60 and 70 years living with diabetes and they had less than ideal A1cs and no presence of any insulin production — amazing! What scientists think these patients do have in common is some kind of endogenous protective factor, and they are trying to discern exactly what it is.

The medalists’ longevity did, however, seem related to two things. One, exercise- typically 30-40 minutes of moderately vigorous activity almost daily. Many were actually active ballroom dancers. And, they seemed to have a high level of HDL, the good cholesterol. 2) Positivity. I found it particularly interesting that they also shared being unusually friendly. In the words of the key researcher, Dr. King, in a roomful of patients he can identify the medalists purely on personality. A psychological study seems to back him up: Medalists were found to rate high on a positivity index.

So, I think the key lesson is make sure you get your exercise and when your partner steps on your dancing shoes, smile and keep on dancing!

50 Diabetes Myths soon at a store near you

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Screen Shot 2015-02-08 at 11.19.37 AMInvaluable information coming this summer

O.K., I can’t tell you how exciting this is…well, actually I can and I will! I just finished the manuscript for my forthcoming book– 50 Diabetes Myths That Can Ruin Your Life: And the 50 Diabetes Truths That Can Save It. It will be out late June and in bookstores this summer. 

Yes, hunkered over this computer, I just wrote the last word, just looked at all 272 pages for the last time and just said to a friend, “Yes, I can meet you for dinner tomorrow.” No one’s heard that from me for quite a while.

21 top diabetes experts across the spectrum of diabetes care — food, medicine, fitness, psychology, technology, research and more — consulted with me so that you’ll have all the latest info, stories of fellow patients’ experiences, great, easy tips and, yes, even learn what I was startled to discover while writing this book. You’ll also get to know a lot of juicy stuff about me, but probably more important, (yes, only kidding) you’ll be amazed at the things you think are true, that aren’t–and that makes all the difference between just getting by and improving the quality of every day and very likely lengthening your life. Even a doctor friend who also gives presentations to fellow diabetics said while reviewing my draft that he couldn’t believe how much he didn’t know. 

So mark your calendar to get your copy of the only book that clears up the confusion, exclusively, about diabetes myths. Am I shamelessly selling you my book? You bet! But then I wouldn’t have spent a year of my life writing it if I didn’t believe it will make a huge difference to your life. 

If you think any of these are true, you owe it to yourself to read this book: 

Type 2 diabetes isn’t as serious as type 1 

There’s no real relief for the tingling/burning in my feet 

I can’t eat my favorite foods

Diabetes has nothing to do with my teeth 

If I have to use insulin I’ve failed 

Plus 45 more intriguing “myths” and “truths” all coming your way in July. Hmmm…guess it was a good thing I used to be in advertising. 

Even diabetes gods have occasional hoofs of clay

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So there I was at the Norfolk, Virginia airport having just gone through security and Starbucks (aren’t they both required?) when I feel my  heart beating rapidly, my hands shaking and I know that it’s not the caffeine: I’m entering low blood sugar land. The airport is relatively empty so I drop my rolling case where I am, not far from my gate, fish for my key, unlock my case, then open the zipper of my packed knapsack and rustle out my meter. 

What must I have been thinking, (or not), when I packed my meter inside my knapsack and locked it inside my small suitcase that would get handed to the baggage guy just outside the plane door as I board? I had flown down from New York to Virginia to speak at a health fair to fellow patients about developing healthier habits for living with diabetes — admittedly this isn’t one of them! Was I unconsciously packing away my diabetes now that my job was done and taking the day off? Going incognito so to speak?

My meter on top of my case now proves my suspicion correct: 51 mg/dl, and while I don’t have a CGM I clearly know I’m going down. I close up my case and wheel it, and me, to my gate so if anything should happen there will be others around. I sit not far from a grandmotherly looking passenger in the waiting area and unpeel the tangerine I also packed in my locked case. Well, at least I was smart enough to bring a sugary food in case this should happen. So somewhere at base camp riva I wasn’t going to let anything too drastic happen. (Yes, I had my SweeTarts with me but wanted to use up that tangerine already, and knew I had the low blood sugar window open enough to do so.) I actually brought that tangerine down with me from Brookyn two days earlier. Now it was doing its job. Peel, munch, ask grandma where she’s going like I’m perfectly in my body, peel, munch, “Really, on a cruise you say, around Asia? How nice.”

Fifteen minutes or so later, another low handled and danger averted. As my collective brain cells kick in I revisit why I didn’t have my meter easily accessible and was willing to have it in cargo during the flight. After all I was in the perfect situation to have a low: traveling, off my routine, and while I ordered from room service that morning my usual hot oatmeal, the hotel didn’t know the secret “riva receipe:” a dollop of low fat yogurt and cottage cheese on top for stabilizing protein, bits of apple and berries for more rapid glucose, and a tablespoon of peanut butter for fat to sustain and level my blood sugar rise. 

Best I can figure, on some unconscious level there are just times I want to be an ordinary jane (I’d say ordinary cow, see photo, but it doesn’t sound very nice even in a frilly pink dress) and I yearn to put me, riva, before my diabetes. Judging from results I guess I’m willing to walk the line at times between being fully at the ready and knowing I can pull out my Super-Diabetic cape at any moment and save the day. 

I’m sure that confidence comes from knowing that cape is with me wherever I go: All my knowledge, learning and experience, and so maybe that’s why at times I pack it rather than wear it. For all of us who recognize this scenario, yesterday was just another day in funky-town, one for rebooting and reflecting and with that, maybe I’ll see if that cape can drape over these cow shoulders if I do want to wear it next time. 

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. 

Test your food knowledge!

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Screen Shot 2015-02-08 at 1.29.29 PMStill more to learn about healthy food choices

Working at home, I try not to miss Oprah when Dr. Oz makes an appearance, usually it’s a Tuesday and usually I’m procrastinating. Last week Dr. Oz and David Zinczenko, editor-in-chief of Men’s Health magazine were helping overweight teens better understand calories, fat, how much one needs to eat, serving size, etc. Safe to say, it was a good lesson for us grown-ups too. 

Mid-way thru the program the doctors gave Oprah and the audience a quiz comparing two foods/meals, many of which are in Zinczenko’s new book,Eat This Not That For Kids. Which of the two meals/foods below they asked are healthier based on calorie, fat and sugar content. Guess what? Most of the audience, including moi, failed miserably. 

1. Turkey bacon or regular bacon? Answer: Regular bacon. Both turkey bacon and regular have the same amount of calories and fat, but turkey bacon has a ton more sodium. Why? To make it taste like regular bacon!

2. A multi-grain bagel with low fat cream cheese or a glazed donut? Answer: Glazed donut. The multi-grain bagel and cream cheese have 500 calories compared to the donut’s 180 calories. And don’t be fooled — the multi-grain bagel is refined carbohydrate. Just because it’s got a variety of grains doesn’t mean they’re whole grains, and when it comes to bagels, they’re not.

3. Bacon and eggs or French Toast sticks? Answer: Bacon and eggs. It’s got 250 calories compared to the toast sticks 400 calories! 

Enough to say, even when you think you’re pretty smart about eating healthy, you can still be fooled. Zinczenko’s book has many more of these shocking food comparisons and I think it’s just as apt we adults learn this as kids. 

One of the few questions I actually answered correctly is don’t skip breakfast! Most people who do consume 450 more calories/day.

More tips for timing insulin

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A few posts ago I extracted some very valuable information from an article CDE and dietitian, Hope Warshaw wrote titled, “Rapid-Acting Insulin, Timing It Just Right” and I’d like to share a little more of her knowledge.

 Fine-tuning the timing of your premeal boluses or injections is important, but no more so than knowing how to count the carbohydrates in a meal or snack. If you don’t know how to count carbohydrates or to match your insulin dose to the amount of carbohydrate you plan to eat, speak to your health-care provider. Many people find themselves in a reactive mode when it comes to dosing insulin, taking it in response to high blood glucose rather than using enough of it before a meal to cover the rise of blood glucose in the hours after a meal or snack. Experts agree that it’s much harder to bring high blood glucose back down than to control blood glucose levels with sufficient insulin in the first place.

Glycemic Index: The glycemic index of foods as well as the fiber and fat content dramatically affect how quickly or slowly blood glucose level rises. (The glycemic index ranks foods based on how quickly they raise a person’s blood glucose.) One tip since most people’s blood sugar rises most quickly in the morning is to eat low glycemic foods at breakfast like yogurt or a bowl of oatmeal with a piece of fruit rather than foods with a higher glycemic index such as some cold cereals, pancakes, or muffins.

In general, foods and combinations of foods that have a low glycemic index and high fiber content will raise blood glucose more slowly. Conversely, foods with a high fat content tend to cause a delayed rise in blood glucose. The extent to which the glycemic index or fat content of a meal speeds or slows the rise in blood glucose following a meal varies from person to person. 

Meticulously timing your rapid-acting insulin dose and carefully calculating your dose according to the carbohydrate you will eat is usually best for blood glucose control, but it may not always be possible. There are times when you know exactly when and how much you will eat and times when you don’t. The following  tips may help you adjust for the realities of daily life:

High blood glucose before a meal. If your blood glucose is high before a meal, use how much your blood glucose level falls in response to one unit of insulin to calculate a dose of rapid-acting insulin to cover the high, then wait until that insulin begins to lower your blood glucose before you eat. 

Claudia Shwide-Slavin, a dietitian and certified diabetes educator in private practice in New York City, advises the following: “If your blood glucose level is between 140 mg/dl and 180 mg/dl, take the rapid-acting insulin and wait half an hour before eating. If it’s between 180 mg/dl and 200 mg/dl, wait 45 minutes. If it’s higher than 200 mg/dl, wait at least an hour.”  If a person is hungry or must eat at a specific time, Shwide-Slavin recommends limiting the amount of carbohydrate at the meal by eating mainly protein and nonstarchy vegetables.

Low blood glucose before a meal. If your blood glucose is low before a meal (below about 80 mg/dl), “Wait to take your insulin,” says Shwide-Slavin. “Let the food have 15 minutes to raise your blood glucose before taking your insulin.”

So, a few few more helpful hints to put your management “in the zone.” 

 

 

 

Secrets to a longer, healthier life

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Intrigued already aren’t you? This is just one of the 15 self-assessment quizzes and tools for better managing your health and diabetes on the MayoClinic’s web site. The Secrets quiz asks just 10 questions and while I can tell you the answer doesn’t involve an anti-aging pill, it does involve some basic lifestyle changes– but the quiz will help you personalize what those changes are for you.

I’ve often used the MayoClinic web site as a valued resource for information but wasn’t aware what a plethora of diabetes tools and information it offers. It was actually meeting Julie in Queenstown, New Zealand, while on my recent travels, that I learned more about the MayoClinic’s dedicated diabetes work. Julie, who has type 2 diabetes, participates monthly in a research focus group with the clinic so that they get a fuller perspective on patient issues. 

While diabetes blogs and social networks are mushrooming like a fungus, it never hurts to go back to basics and review treatments, management strategies, coping, and ask questions of specialists from a well-trusted resource such as this.

Learning more about timing insulin

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I know a lot about diabetes and working with my insulin. But recently a friend sent me an article, “Rapid-Acting Insulin, Timing It Just Right”, written by well-noted certified diabetes educator and registered dietician, Hope Warshaw. It helped confirm some of what I know and helped clarify some of what I didn’t know about timing insulin with your meals. Here are some of the article’s highlights.

Warshaw points out that even when you think you’re doing everything right with your diabetes care regimen, your blood glucose levels can seem hard to control. One potential source of difficulty is how you time your injections of rapid-acting insulin with respect to meals.

Most diabetes experts recommend taking meal-time insulins (Humalog, Novolog and Apidra) within 15 minutes of starting a meal. This advice is based on the belief that rapid-acting insulin is absorbed quickly and begins lowering blood glucose quickly. However, this may not be true for everyone. 

Howard Wolpert, M.D., editor of the book Smart Pumping and Senior Physician and Director of the Insulin Pump Program at Joslin Diabetes Center, cautions against blind-faith acceptance of insulin action curves or standard advice about when insulin works, noting that insulin can show “a lot of variability…between individuals and even within the same person from day to day.” The time ranges given for an insulin to reach its peak action are averages, so they may not fit everyone or every situation. You may find through blood glucose monitoring and experience that rapid-acting insulin typically reaches peak effectiveness within 45–90 minutes or possibly sooner or later. In general, people with normal stomach emptying can expect some glucose from the carbohydrate they’ve eaten to start raising their blood glucose level within minutes of starting to eat. Blood glucose level tends to peak about one to two hours after the start of a meal and gradually drops over the next three hours.

If rapid-acting insulin always started working almost immediately and peaked one to two hours later, injecting it anytime within 15 minutes of starting to eat would work well. But newer observations suggest that rapid-acting insulin doesn’t get absorbed and start working that quickly in all people. John Walsh, P.A., C.D.E., coauthor of the book Using Insulin, for example, believes the maximum blood-glucose-lowering effect of rapid-acting insulin may occur much closer to two hours after an injection rather than 45–90 minutes. If this is the case, the optimal time to take rapid-acting insulin is 10 to 15 minutes before eating rather than with the first bite or 15 minutes after starting a meal. Walsh’s belief is based on research suggesting that insulin may be measurable in the bloodstream before it begins actively lowering blood glucose.

 

Some other factors that may cause insulin action to differ from the action curve given in product literature or to vary from person to person include thickness of the subcutaneous fatty layer at an injection site, temperature, blood flow, exercise, and dose size. (The choice of injection site—abdomen, thigh, arm, buttock—does not seem to affect the absorption rate of rapid-acting insulin as it does for slower-acting insulins.) Injecting into areas that have more subcutaneous fat tends to slow insulin absorption. Widened blood vessels (caused by higher temperatures or exercise) allow insulin to be absorbed more quickly; constricted blood vessels (caused by colder temperatures or smoking) can cause slower absorption. Large doses of insulin may also be absorbed somewhat more slowly than smaller doses.

Thank you Ms. Warshaw. Since this is a lengthy article there’ll be more from Hope’s article over the next few posts.