Just in time for the holidays, November is National Diabetes Month. Who cares? You might. According to the National Diabetes Education Program:
Approx. 26 million Americans have diabetes.
An additional 79 million adults in the US have prediabetes.
The total direct medical cost of diagnosed diabetes in 2012 was $176 billion.
Two diabetes awareness campaigns caught my attention this year:
Lee Ann Thill created the World Diabetes Day Postcard Exchange to "promote healing through creativity, connection and activism." Participants in the Exchange send and receive handmade postcards that incorporate the blue circle (the international symbol of diabetes) in their design. Great idea - I'm mailing my cards today.
The Big Blue Test is designed to help people notice the impact of small changes. Through November 14, for every 10 Big Blue Test results that are logged, Diabetes Hands Foundation grants $5 to support people with diabetes. You don't have to have diabetes to participate, and the benefits of exercise are yours to keep. Here's what to do:
1) Test your blood sugar (if you have diabetes)
2) Move your body (at least 14-20 mins)
3) Test again (if you have diabetes)
4) Share your results on bigbluetest.org
I've been logging my big-blue data since the start of the campaign. Each time, my blood glucose has dropped 20-30 points following 60 minutes of moderate-to-vigorous exercise. Plus, I use 15% less basal insulin for the ensuing 4 hours.
That's some solid motivation right there.
When my endocrinologist suggested earlier this month that I go on a statin to lower my LDL (damn you, diabetes!), I didn’t love the idea. I agreed to think about it, but in truth, I began at once exploring alternatives. To begin with, I wanted to understand if my lipid numbers were in fact problematic.
Should I even worry about my cholesterol levels? According to the American Diabetes Association (ADA), people with diabetes should meet the following targets:
The role of cholesterol in our bodies seems poorly understood. For years I believed in the protective benefit of HDL - the idea that a high HDL would offset a high-ish LDL. But this 2012 New York Times article points out that view may be outdated.
(So a high HDL isn't necessarily helping me avert heart disease?) I was further encouraged by another briefly popular notion that what mattered more than the individual numbers was the ratio of HDL to total serum cholesterol. The American Heart Association (AHA) has stated that a ratio of <3.5:1 is ideal. And yet, the AHA has not incorporated the metric into their clinical practice guidelines. (So much for my own reassuring ratio of 3.55:1.)
Therefore, barring other measurements, I am resigned to the fact that the individual cholesterol numbers matter at this moment in time. Which leads to the question of treatment:
Should I lower my LDL with a statin?
Again, according to the ADA, yes. The ADA maintains that: Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients without CVD (cardiovascular disease) who are over the age of 40 years and have one or more other CVD risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria.
There’s no question that statins lower cholesterol, but for whom, to what degree, and with what effect remain unclear. Statins' success in secondary prevention – helping people (particularly men) avert a second heart attack or stroke – is well documented. But their effectiveness for primary prevention (initial heart attack/stroke) is less clear. It turns out that cholesterol levels may be less predictive of cardiovascular disease (CVD) than previously thought. (This 2012 Journal of American Medicine piece suggests the controversy).
Even if the indication were more certain, the benefits would have to outweigh the potential side effects linked to statin use (see the FDA's current consumer advisory on statins), notable among them: muscle pain, cognitive interference, and – wait for it – elevated blood sugar.
On the NIH’s National Heart, Lung and Blood Institute website, I found a simple (now outdated)risk assessment calculator* where you can plug in different cholesterol numbers and see how they affect your 10-year risk of heart attack.
(I calculated mine based on my recent lab work: 1% risk. Not very statin-worthy.) * 11/12/2013 update: new cholesterol treatment guidelines were published today. Per these new recommendations, anyone between the ages of 40 and 75 who has Type 1 or Type 2 diabetes should be on a statin (period). However, I used the brand new calculator (which now includes stroke risk) to gauge my 10-year risk of heart attack or stroke. .04%. So, thanks, I guess, for the new guidelines, but I'll still pass on the statin for now.
Despite my skepticism, I don’t want to give my newish endocrinologist the impression that I ignore her advice. There seems to be no harm in trying to lower my LDL naturally.
My plan to reduce my LDL without a statin Reputable web sites assure me that diet and exercise may help lower my LDL by 20-30%. The added bonus for me is that I’ll get more fit in the process. Excellent! So:
I upped my gym visits to 5-7 days/week.
I found my long-lost pedometer and am logging at least 7500 steps/day.
Oatmeal or soup (why not?) for breakfast.
Meat and dairy are now occasional indulgences.
On the upside, I figure I’m just leveraging diabetes to make myself healthier.
(Take that, diabetes!)
I promised to share how LiveWell's Get Movin' Challenge is working for me.
It's been great so far! Since August 1, I have engaged in the following activities:
enjoyed volleyball & picnic in the park with other families participated in the super fun Viva Streets (Coloradans, join me next year!) played tag at a park with my children swam while my kids had swim lessons bounced with my kids at an indoor trampoline park worked out at the gym 3-4 times per week hiked with my family took my children to a roller rink and skated with them
Most days I exercised for more than 45 minutes. I found that even when I had met my daily exercise goal, I continued to seek additional opportunities to be active.
On the other hand, there were days - three of them - that I didn't squeeze in my 30 minutes. I made up for it by exercising twice as long the next day.
Since part of the goal I had set for myself was to try new forms of exercise, and I still haven't got to everything on my list, I'm taking the challenge into September.
Here's what's on deck:
go on a bike date with my husband
commit to one car-free (or walk-only or bike-only) day in September
add one class to my fitness routine (cycle or power yoga)
I ditched my Saturday AM gym workout in favor of a family hike with good friends who live in Boulder. I expected we would be gone all day and considered taking my back up insulin and needles, in the unlikely event I might need them. But it was hot - close to 100 degrees - and insulin needs to stay cool. We were out of ice and I hadn't prepped my FRIO and I was concerned the insulin would get too hot in the car. So opted to leave my backup insulin and needles at home (and now you know where this story is headed).
We were hiking with small children, so as it turned out, it wasn't the most vigorous exercise. But it was a stunning Colorado hike.
Afterward, we picnicked in downtown Boulder. As I was unsure what the hike had accomplished for me metabolically, I dosed conservatively, planning to check my blood sugar again in an hour and re-dose as needed.
I didn’t have the chance to re-dose. Instead, 15 minutes post-meal, my pump alarm sounded. That usually means one of three things:
Check Blood Sugar / Just ate - too soon to check.
Low Battery / Inserted fresh battery that morning.
Low Insulin Supply / Replaced the infusion set and insulin the night before.
The beeping was getting louder and more urgent. It now had my full attention.
I unclipped the pump from my clothing and consulted the screen:
Sounds fairly innocuous, right?
I tried to cancel the alert. No luck.
I tried to back out of the screen.
Again, no dice.
Suddenly, as though impersonating a Vegas slot machine, the pump began wildly scrolling through three-digit numbers – numbers so big it was downright uncomfortable to see them on an
I excused myself and called Medtronic.
Within five minutes, a customer service representative was assuring me that my pump was still under warranty so Medtronic would send me a new one, for free. How great of Medtronic and what a relief. It made the next part easier to swallow.
Medtronic: If you don’t receive your pump by Tuesday, please give us a call.
Woah. Tuesday? (This was Saturday.)
Me: I hope I don't sound unappreciative, but Tuesday is three days from now. Medtronic: Yes. Me: Do you know that the pump is what I use all the time to manage diabetes? Medtronic: Yes. You will have to move to your backup plan. Me: Okaaaay.
People with diabetes have lots of back up plans. We have plans for high-fat meals, plans for high-carbohydrate meals, for delayed meals, for exercise, illness, stress, unexpected lows, stubborn highs... But a backup plan for all-out pump failure? Nope. I didn't have that. Plus, my short-term back up plan was at home in the fridge.
So, there we were in Boulder with our friends, the kids, and the dog we were looking after. How much active insulin did I have on board? I really didn’t know.
So we went home. And I considered how to be pump-free for three days.
Option A – Multiple Daily Injections (MDI) MDI therapy generally utilizes two types of insulin – short- and long-acting insulin. The long-acting insulin stabilizes blood sugars between means, the short-acting one covers food. Insulin pumps eliminate the need for long-acting insulin because it works as a healthy pancreas does – continuously delivering micro-doses of background insulin. And that’s fantastic, but it's also the reason I don’t have a prescription anymore for long-acting insulin. So, to temporarily implement an MDI approach, I would have to call my newish endocrinologist – the one I really don’t have a relationship with yet – on a Saturday for a prescription. A vial of lantus would cost $120. I’d use it for three days and throw it away (it lasts for a month when opened). Not ideal.
Option B (Please read this disclaimer before reading on.) What if I could mimic the pump, giving myself little micro-doses of short-acting insulin throughout the day and night?
Had other PWDs considered this route? I went online found several pumpers who had apparently used this approach with some success. I decided to try it. Feeling that night time would present the greatest risk, I set my alarm for every two hours and gave myself teensy doses of insulin. The next night, I checked only every 3 hours. The night after that, I checked only once. It was tiring, but I stayed between 89-133 every night. I was glad to know I could do that in a pinch, but very, very glad when the pump arrived at my door Tuesday morning.
In the end, I am reminded how much I appreciate my insulin pump, the company that makes and supports it, and the DOC.
One of the assignments in my nutrition MOOC involved keeping a food diary for a day and making nutritional observations. The assignment effectively reinforced the course concepts. A bonus in this international class, is seeing what people in various countries eat, say, for breakfast. Pumpkin - really? (Yep. Bangladesh.)
People with diabetes are often asked to provide our medical teams with detailed logs about our food intake, exercise and blood sugars. It's not uncommon for my endocrinologist to request 1-2 weeks of data in order to see patterns and trends and better understand how my diet and exercise might be affecting my blood sugar. As valuable as I know the results are, the process of calculating and recording the data is monumentally tedious. (Thankfully it's a little less cumbersome since the advent of nutrient-tracking apps like MyPlate Calorie Tracker, MyFitnessPal.)
For the Coursera assignments, my classmates and I use SuperTracker, the USDA’s free, online tracking tool designed to help people meet their exercise and nutrition goals. Unlike many other apps in the food diary space, SuperTracker includes the option to track micro-nutrients (vitamins and minerals). I haven’t ever paid attention to micro-nutrients, so I was surprised to discover that on a typical day my calcium intake falls far below the recommended levels for women in my age group.
I researched how to work calcium into my diet. I knew about some of these calcium power-houses, but some (figs?!) were new to me.
2 TBL blackstrap molasses
2 cups low-fat yogurt
1 cup milk
1 cup broccoli
½ cup navy beans
2 TBL sesame seeds
1 cup arugula
1 hard boiled egg
¼ cup chick peas
1 dried fig
Since our garden is teeming with greens, I’ll begin with a calcium-rich salad.
#28 on Bittman’s seasonal salads fits the bill.
I just signed up for LiveWell Colorado's Get Movin’ Challenge. For those who are unfamiliar with it, LiveWell Colorado is a nonprofit organization committed to reducing obesity in our state. The challenge invites Coloradans to commit to one month of physical activity – at least 30 minutes a day every day – during the month of August.
As it happens, my kids are enrolled this week in a sports-oriented camp.
A typical day looks like this:
I would not have described either of my children as particularly sporty. And yet, they return home from camp each day raving about how much fun they had scaling the climbing wall and learning to play lacrosse.
That got me thinking – I should make my workout more fun. Here’s how I'm going to do that during the Get Movin’ Challenge:
add two classes to my fitness routine (I picked spin and power yoga)
take my family hiking twice over the next 5 weeks
schedule an evening soccer or volleyball game in the park with other families
commit to two car-free (walk- or bike-only days) in August
go on a bike date with my husband
take another Will Power and Grace class with my friend
I'm in week three of "Nutrition for Health Promotion and Disease Prevention," the MOOC (Massive Open Online Course) I posted about recently. This is my first experience with a MOOC and so far I'm impressed and intrigued. I see enormous potential in the format. I only wish I had more time to spend on the discussion boards interacting with the other very many other people in the class.
Did I mention that there are 25,000 students in the class? (That's not a typo.) 25,000 active participants from all over the globe - Korea, Cameroon, USA, Venezuela, Ethiopia, India, Romania... it feels really amazing to be in class with such an extremely large, global community.
As a result, I'm thinking about food from refreshingly new perspectives. For example, the focus of this week's lectures is the role of nutrition in diabetes management and prevention. One of the assignments is to create a meal plan for someone with diabetes. OK, that part is not refreshing since it's something I do everyday. But once we completed the class... [Update: Here's the Diabetes Meal Plan I designed according to the assignment parameters.]