The Goofus and Gallant of Diabetes

NEWSLETTER
MY
Summer 2015 Volume 52
The Goofus and Gallant
of Diabetes
Dr. Edelman’s Corner
INSIDE
Keeping It All in Perspective
Page 3
Ask Your Pharmacist
Page 4
Giving Back
Page 6
Product Theater
Page 7
See Me. See Diabetes.
Empowerment Challenge
Page 8
Summer Recipe by
Diabetic Living
Page 10
Preventing the Shark Attack
(Topic of the Month)
Page 11
R
emember Highlights? For over 60 years it has been a very popular
magazine for kids with lots of stories and games that make you think.
When I was younger, I loved the section called Goofus and Gallant.
They were two guys, one of whom was kind of dorky and goofy and
always did everything wrong, and the other was polite, proper and did
everything right. Look at the scenarios below and see if you relate to
Goofus or Gallant.
Goofus has type 2 diabetes and
hates to take prescription medications,
adamantly refuses insulin, and his goal
in life is to “get off all medications.”
As a result, he stopped his medications
or takes them very sporadically before
his doctor visits…if he shows up at all.
He has poorly controlled glucose values
(A1c above 8%), elevated LDL
cholesterol levels, and high blood
pressure. He does, however, take tons
of over the counter supplements from
the vitamin store to treat anything from
diabetes, memory loss, and male pattern
baldness to daytime tiredness and reduced
energy. He constantly brags to his friends
and family that he does not take any
prescription medications at all!
Goofus and Gallant (continued on page 2)
Goofus and Gallant (continued from page 1)
Special
Acknowledgements
Board of Directors
Steven V. Edelman, MD
Founder and Director, TCOYD
Sandra Bourdette
Co-Founder and Executive Director,
TCOYD
Edward Beberman
Christine Beebe
Audrey Finkelstein
Margery Perry
Daniel Spinazzola
Andrew Young
Contributing Authors
Jennifer Braidwood
Steven V. Edelman, MD
John Garrett, MS, 4th Year Student
Susan Guzman, PhD
Candis M. Morello, Pharm D
Brittany Newton, 3rd Year Student
Jeremy Pettus, MD
TCOYD Team
Steven V. Edelman, MD
Founder and Director
Sandra Bourdette
Co-Founder and Executive Director
Jill Yapo
Director of Operations
Michelle Day
Director, Meeting Services
Michelle K. Feinstein, CPA
Director of Finance and Administration
Jennifer Braidwood
Manager, Outreach and Communications
David Snyder
Manager, Exhibit Services
Robyn Sembera
Manager, Continuing Medical Education
and Publications
Sarah Severance
Administrative Assistant
MyTCOYD Newsletter
Editor: Robyn Sembera
Assistant Editors: Jennifer Braidwood and
Sarah Severance
Design: Hamilton Blake Associates, Inc.
MyTCOYD Newsletter is offered as a paid
subscription of Taking Control Of Your Diabetes. All material is reviewed by a medical
advisory board. The information offered is
not intended to constitute medical advice
or function as a substitute for the services
of a personal physician. On the contrary, in
all matters involving your health, TCOYD
urges you to consult your caregiver.
©2015 All rights reserved.
2 My TCOYD Newsletter, Vol. 52
Gallant also has the diagnosis
of type 2 diabetes, as well as the
commonly associated cardiovascular
issues of abnormal cholesterol and
high blood pressure. His diabetes
medication list includes Glucophage
(metformin), Invokana (canagliflozin),
Bydureon (once weekly exenatide),
Novolog (insulin aspart), and Lantus
(insulin glargine). He is also taking
two drugs to control his blood
pressure (fosinopril and diltiazem)
and one pill for his cholesterol
control (simvastatin). Gallant
would rather not have to take the
long list of medications; however,
he has a good relationship with his
doctor, understands how important
medications are for the prevention
of complications down the road, and
takes his medications religiously (not
just on Christmas and Easter). His
A1c is 7.2%, LDL is at goal (below
100), and BP on average is extremely
good (~125/82 mmHg).
If you have type 2 diabetes, are
you more like Goofus or Gallant?
In this scenario, Goofus has
type 1 diabetes and wears a Tandem
insulin pump, but his A1c has been
well above 9% for years. He tests
his blood glucose level from zero to
two times a day because he says, “I
can feel what my BS is so I do not
need to test.” Goofus drinks regular
soda because he “does not like the
taste of diet.” He adamantly refuses
to use a continuous glucose monitor
that has been offered to him by his
endocrinologist even though he has
had several hypoglycemic reactions
at work, while driving his car, and at
home; some severe enough to require
assistance from others. When he
recognizes his lows, he typically eats
two or three Snickers bars. He gets
up at night to urinate two or three
times and is really tired and falls asleep
during the day on the job. His wife
commonly threatens to divorce him
because she is tired of trying to watch
over him. He was prescribed an ACE
inhibitor (medication that protects the
kidney) and a statin to keep his LDL
cholesterol low but he stopped taking
Goofus and Gallant (continued on page 12)
TCOYD in Motion
had to bail some of his patients out
of jail after they were arrested for
being “publically intoxicated” when
they really just needed some juice!
Police officers had never heard
of hypoglycemia before so they
just assumed all these poor hypodiabetics were drunk.
Another thing that jumped
out at me was how doctors had
to decide whom to give insulin
to. Insulin was available but it was
still in limited supply so it had to be
rationed. They made the decision to
basically under-dose a large number of
patients rather than appropriately dose
a few. “We felt it more humanitarian
to prolong the lives of many old and
By Jeremy Pettus, MD, Assistant Professor of Medicine, UCSD
faithful patients rather than attempt to
Type 1 Track Co-Director, TCOYD
secure marvelous results in a few.” As
some of you might know, the previous
recently got my hands on a
it requires brains to live long with
“treatment” for type 1 diabetes was
publication from Elliott Joslin
diabetes, but to use insulin requires
that he wrote regarding his first
more brains.” Sounds to me like this starvation so results, as you might
imagine, were not good. Patients were
experiences treating patients who
guy got it. In fact, I want to make
on the razor edge
had diabetes with insulin. The
up t-shirts that say,
between dying
publication was written in 1922,
“It takes brains to
“We felt it more
of DKA (diabetic
after insulin had been available for
use insulin,” with
ketoacidosis)
humanitarian to prolong
only a handful of months. What
an arrow pointing
and dying of
I found most striking were the
to my pump on
the lives of many old
starvation. Then,
similarities between what patients
my arm.
and faithful patients
suddenly, insulin
and providers were dealing with
Joslin goes
rather than attempt to
comes into the
then and what we deal with now.
on to describe his
secure marvelous
picture, a lifeJoslin discusses in great detail the
first experiences
results in a few.”
saving treatment,
difficulty of adjusting insulin levels,
with hypoglycemic
and it is up to
and modifying diets and exercise
patients. Keep
these docs to distribute it. It was also
levels. With all these different factors in mind that hypoglycemia didn’t
mind boggling that doctors would only
to manage Joslin explains, “Insulin
really exist before insulin and is
intermittently treat patients; they
is a therapy that is primarily for the
largely something we have created
would stabilize their patients with
wise and not for the foolish, be they with medical interventions.
patients or doctors. Everyone knows Apparently, the good Dr. Joslin
Keeping It All in Perspective (continued on page 5)
Keeping It All
in Perspective
I
Taking Control Of Your Diabetes
3
Ask Your Pharmacist
Another SGLT-2 Inhibitor
Has Come Your Way!
By Candis M. Morello, Pharm D, CDE, &
John Garrett, MS, 4th Year Student Pharmacist
J
ardiance (empagliflozin) has
recently made its appearance on
the marketplace to help people with
type 2 diabetes stay in control. This
SGLT-2 inhibitor is also available as
a combination pill called Glyzambi,
which is mixed with Trajenta
(linagliptin), another commonly
used diabetes medication that works
by a different mechanism to control
the glucose levels.
What is Jardiance
(empagliflozin)?
Jardiance is the third drug in a
new class of diabetes drugs called
SGLT-2 inhibitors, along with
Invokana (canagliflozin) and Farxiga
(dapagliflozin). The main advantage
of Jardiance, as well as Invokana and
Farxiga, compared to many of the
older diabetes drugs is that it is less
likely to cause hypoglycemia, and
can lead to weight loss.
How Does Jardiance Work?
Jardiance lowers your A1c and
4 My TCOYD Newsletter, Vol.33
Vol. 52
blood glucose in a very interesting
way- you pee out the excess
glucose. Our body is very good at
reabsorbing urinary glucose back
into the bloodstream. It does this
primarily by a transporter located
in the kidney called SGLT-2
(Sodium Glucose Transporter).
Jardiance is a SGLT-2 inhibitor,
so when Jardiance blocks this
transporter, glucose is excreted out
of the body through the urine and
will lead to an overall decrease in
blood glucose, as well as weight
loss. The amount of glucose that
is excreted from the body into the
urine with Jardiance treatment is
approximately the equivalent of
40-50 sugar cubes a day.
What Can You
Expect?
When starting
Jardiance, you can expect
a moderate decrease in
your A1c (0.5-1.0%,
depending on your
baseline A1c), moderate decrease in
your fasting plasma glucose of
30 mg/dL, a decrease in your weight
(2.5%-5.0% in your body weight
or about three to six pounds), and
a small but significant decrease
in your systolic blood pressure
(2-4 mmHg). The improvements
mentioned above were seen in
clinical trials and your response may
be even better. Since it may cause
you to urinate more frequently, it is
advised that you take Jardiance in
the morning. After a few days, the
frequent urinating should decrease
and you should use the restroom
at about the same frequency as you
would before taking Jardiance.
Some women may be more
prone to urinary tract infections or
female genital yeast infections so
paying attention to proper hygiene
is important. In addition, some
individuals (especially the elderly
or those on diuretics or water pills)
with low blood pressure may get
dizzy, especially initially upon
standing.
Is Jardiance Right for You?
If you have type 2 diabetes,
Jardiance may be an excellent
choice. It is a well-tolerated
medication that by itself does
not cause low blood glucose or
hypoglycemia and will lead to
weight loss. For certain people
with reduced kidney function,
this drug may not be for you. Your
caregiver will check your kidney
function (eGFR or estimated
glomerular filtration rate) before
prescribing Jardiance.
Jardiance may be considered
as an add-on to your diabetes
regimen or can be used alone. As
an add-on to metformin instead of
a sulfonylurea (such as glipizide or
glimepride), patients see a better
reduction in A1c, and have less
hypoglycemia with weight loss.
The Bottom Line
If you are seeking better
diabetes control without
hypoglycemia and weight loss,
Jardiance may be a good option
for you.
Keeping It All
in Perspective
(continued from page 3)
insulin when they were sick and
then take them off it when they
got better. How upset would you
be if somebody took away your
insulin after you got over the flu?!
The idea really just makes me
want to hug a diabetic. Where is
Dr. Edelman when you need him?
Back in the 1920’s, when
insulin was such a rare and
precious medication, could
you imagine the caregivers’
frustration when patients would
either not take the insulin they
were given, or not take the
appropriate dose? Joslin had
this to say, “For the wise, who
may be rich or poor, young or
old, insulin is a benefit but, for
the ignorant, who likewise may
be young or old, rich or poor, it
can be dangerous and the gift
of insulin to such is like casting
away pearls.” It just makes me
think of how much we still take
this life-saving therapy for granted…
both people with diabetes and
our providers.
In the roughly 100 years since
the discovery of insulin, we have
certainly come a long way! We are
living MUCH longer and healthier
lives thanks to this one medication.
I like to think that Elliott Joslin
would be amazed to learn that one
day there would be entire groups
of people with type 1 who would
become successful individuals,
including medical professionals,
activists, moms, dads, athletes, and
so on, and who would come together
to change the world of diabetes.
“Keeping It All in
Perspective” appeared
first on WeAreOne,
a website for medical
professionals, industry
representatives,
activists, and bloggers
who also have type
1 diabetes. To learn
more about WeAreOne or join, please
go to www.weareonediabetes.org
Submitted by:
Candis M. Morello, Pharm D, CDE,
Associate Dean for Student Affairs at
UCSD Skaggs School of Pharmacy and
Pharmaceutical Sciences, Clinical
Pharmacist at VASDHS.
John Garrett, MS, Fourth Year Student
Pharmacist at UCSD Skaggs School of
Pharmacy and Pharmaceutical Sciences
Taking Control Of Your Diabetes
5
Giving Back
Meet the TCOYD
Board Members!
The second in a five article series
“
S
teve Edelman was my son
Michael’s next door neighbor
before TCOYD even existed,” said
Dan Spinazzola, one of TCOYD’s
founding board members. “I got
to know Steve through my son
and we developed a really close
friendship. I was diagnosed with
type 2 diabetes at the age of 50
and from the very beginning of
my friendship with Steve he was
always helping me get through
tough times. He’s done everything
in the world for me,” said Dan,
President and owner of Diversified
Restaurant Systems, a company
that helps restaurants decrease
their expenditures and increase
their quality of food and service.
Dan, a whole-hearted businessman
and one of TCOYD’s longest
standing board members, has
provided TCOYD with years
of guidance regarding best
business practices.
“When Steve asked me to
be one of the board members for
By Jennifer Braidwood
TCOYD I saw a desperate need
in myself, as well as the entire
country, for an organization that
could teach people how to take
control of their diabetes because,
let me tell you, I never met a
dessert that I didn’t like! When
I check my blood sugars and they
are really low, I tell myself, ‘I
need a donut.’ If my blood sugars
are really high I say, ‘Screw it!
I’m going to have a donut’ and, if
my blood sugars are right on track
I say, ‘Wow, I’m doing great! I’ll
have a donut!’
“Most of TCOYD’s board
members are affiliated with the
diabetes industry but I’m just
the guy up the street and Steve
wants to know what I think, so I
am very honored to play my part.
I believe passionately in Steve,
what he says, his knowledge base,
and his theory behind starting an
organization in order to directly
educate people like me to be
their own advocates so they can
Dan Spinazzola
lead healthier lives.
“The reason I continue to
support TCOYD through an
annual gift, as well as my service as
a board member, is because there
is so much passion within TCOYD
and, along with that passion,
there is intellect and energy.
TCOYD is concerned for people
in this country with diabetes.
Dr. Edelman, Sandra Bourdette,
TCOYD’s Co-Founder and
Executive Director, and the rest
of the staff there, they all care—
a lot. They wouldn’t be there if
they didn’t care.
“It is so important to give to
organizations like TCOYD in
order to allow them to continue
providing valuable education,
putting it directly into the hands
of the people most affected by this
disease, people like me and people
like you. So remember to donate
this year!”
Taking Control Of Your Diabetes Is Generously Supported By:
Platinum Foundation Support
6 My TCOYD Newsletter, Vol. 52
Platinum Corporate Sponsors
Gold Corporate Sponsors
Silver Corporate Sponsors
Product Theater
TRULICITY: Once Weekly
Simplicity
By Candis M. Morello, Pharm D, CDE, &
Brittany Newton, 3rd Year Student Pharmacist
I
n September 2014, Trulicity
(dulaglutide) was approved
by the FDA for treating people
with type 2 diabetes. Coupled
with healthy eating and regular
activity, Trulicity can be used by
itself or in combination with other
diabetes medications. Trulicity
joined Bydureon (exenatide
extended release) as a unique
product available for once weekly
injections.
How Does Trulicity Work?
Trulicity is a glucagon like
peptide-1 (GLP-1) analog.
Even though it is synthetic, it
acts similarly to the hormone
GLP-1 naturally produced by
the body, which is deficient in
type 2 diabetes. GLP-1 normally
is released from the intestines
when carbohydrates and fats
are consumed. It helps enhance
pancreatic insulin release, slows
the stomach of emptying food,
and suppresses appetite. This
is known as glucose-dependent
insulin release and is important
in preventing low blood glucose
(hypoglycemia) events. In
addition to increasing insulin
release, Trulicity decreases
glucagon production especially
after eating, which helps to limit
elevated glucose levels.
In addition to affecting the
pancreas, Trulicity also works in
the brain. Here it acts to suppress
appetite, which leads to eating less
and results in weight loss. Lastly,
Trulicity works in the stomach.
In people with type 2 diabetes,
the stomach often empties the
nutrients into the rest of the
intestines too rapidly. GLP-1
analogs help slow and regulate
these actions, which in turn
controls glucose concentrations
after eating.
How Is Trulicity Used?
Trulicity is formulated in an
easy to use pen. Pick any day of the
week that works best for you and
make that your “Trulicity Day!” It’s
as easy as uncapping, placing the
pen on an injection site, unlocking,
and pressing the auto injector
button. After pressing to inject,
hold for 5-10 seconds until you hear
the release click. You never see the
needle! Your doctor or pharmacist
will help you decide what the
best injection site will be for you;
typically this is your stomach, thigh
or upper arm. You should change
the injection site week-to-week by
either changing the area or rotating
within the same area. Once used,
the pen can be disposed of in a
sharps container. New pens should
be stored in a refrigerator, away
from light, and in the original box.
What Can You Expect?
Trulicity lowers both fasting and
postprandial (after meal) glucose in
people with diabetes. A reduction
TRULICITY (continued on page 9)
Taking Control Of Your Diabetes
7
Taking Control
See Me.
See Diabetes.
Launches Its First
Empowerment Challenge
By Susan Guzman, PhD, The Behavioral Diabetes Institute
W
ouldn’t it be nice to feel
like others “get” what it’s
like to have diabetes, and to feel
encouraged and supported in your
daily life?
As a diabetes psychologist,
I have had the opportunity to
hear hundreds of stories about life
with diabetes. The people I know
fall across the whole spectrum of
diabetes: young and old, type 1 and
type 2, low and high A1Cs, newly
diagnosed and those with 50+
years, athletes and couch potatoes,
those who embrace diabetes and
those who try hard to ignore it. No
matter where on the spectrum they
fall, they are all good people doing
their best every day with what is in
front of them.
It is because of all of these
people that I feel compelled to
do more. Every day there are too
many missed opportunities to
explain diabetes correctly (news
articles, bad jokes, doctor visits,
even casual conversations). I get
very frustrated when I hear type 2
diabetes described as the “obesity”
version of diabetes. Why do we
keep replaying that old tape when
we have so much evidence that
genetics, environmental factors,
and other biological causes have
8 My TCOYD Newsletter, Vol. 52
a key role in the onset of type 2
diabetes? Why do people “suffer”
with type 1 diabetes, and why is
type 1 considered the “bad” or
“severe” type?
See Me. See Diabetes. (SMSD)
is a movement to promote a
change in the way we think and
talk about diabetes. The goal
is to challenge misinformation
and stereotypes, and put forward
messages to help all people
with diabetes feel understood,
empowered, and cared for.
On March 7th, 2015 at the
TCOYD conference in Santa
Clara, CA, SMSD launched
with our first initiative, the
No “–IC” Challenge—
a commitment to not
use the word “diabetic”
to describe people with
diabetes.
What’s the big deal
with the word “diabetic?”
It is not helpful to label
someone as their disease. People
have diabetes; they aren’t
their diabetes (you wouldn’t
call somebody with cancer a
“canceric”). While it is easy short
hand to say “diabetic”, it doesn’t
communicate anything helpful
about diabetes. People with
diabetes are a very diverse group of
people with different needs, living a
life with diabetes.
The No “-IC” Challenge
encourages people living with
diabetes to tackle misinformation and
stereotypes by taking the opportunity
to say what diabetes is and what they
would like others to know about it.
When you say “diabetic,” what
are you really hoping people will
understand? Say that instead.
For example, if you are at a
restaurant with co-workers and
decide not to have dessert, or feel
pressured to join in, instead of
saying, “I’m diabetic so I can’t have
any,” say: “I have type 2 (or type
1) diabetes and I am careful about
the carbohydrates I eat. I can have
sweets, but have to pick and choose
when it is healthy for me to have
them.” This extra effort challenges
misinformation and educates others
about diabetes.
What if being called “diabetic”
doesn’t bother me?
The purpose of this challenge
is to take a small step towards
promoting empathy and
understanding about life with
diabetes, not to make people
offended by the word “diabetic”.
Even if being called a diabetic doesn’t
bother you at all, you can still take
the challenge. One woman who has
joined the SMSD community wrote:
“When I first heard about the
No -IC Challenge, I thought ‘eh,
it doesn’t bother me all that much,
but I’ll think about it.’ And I did,
actually a lot. I work with children
with special needs and work hard to
promote, “people first language”
(children with autism rather than
autistic kids). Today, the No-IC
Challenge hit home, and pretty
hard. I posted a picture of my
Dexcom on Facebook, showing
the 4th “Drop Rate” alarm and
it wasn’t even 10a.m. yet. I was
feeling defeated and weighing
my options when a distant friend
replied to my post with a picture
of Wilford Brimley and
the caption “What if I said
Diabeetus?” I didn’t think
anything of it. It wasn’t funny
but it wasn’t offensive to me
either. But then my husband
saw it and was livid. He’s tired
of people making diabetes jokes
and making me feel like my
disease isn’t important. After all,
it’s not cancer and we DO have
more options now...but it’s still
something I have to fight and take
into my own hands. I still wake up
at 4 a.m. with scary lows and scary
highs, and my husband is by my
side through all of it. I’m realizing
now that the No -IC Challenge is
about more than me.”
­ – Brittany R., Santa Clara, CA
We hope that you will take
the challenge and we want to hear
how it goes! SMSD is a supportive
on-line community for people
with diabetes to share their stories,
their challenges,
and their victories.
Join the movement
and help us get the
conversation started
at SeeMeSeeDiabetes.com.
TRULICITY
(continued from page 7)
of A1c from 0.7-1.6% can be
expected when used by itself
or in combination with other
medications. Additionally, many
patients have experienced weight
loss while on this medication.
The most common side
effects of Trulicity include upset
stomach and nausea. These initial
symptoms usually improve after a
few weeks on the medication, as
your body is getting used to it.
Because of how Trulicity
works, it poses little risk of
causing low blood glucose.
However, combining Trulicity
with drugs such as insulin
or sulfonylureas (glipizide,
glimepiride, or glyburide) may
increase the risk of low blood
glucose.
Is Trulicity Right for You?
Trulicity will help achieve
glycemic control in type 2
diabetes patients along with
diet and exercise. Although it
isn’t recommended as the first
medication to treat diabetes
(metformin or Glucophage are
usually first line therapy), it
typically leads to a significant
decrease in A1c, especially when
coupled with other diabetes
medications like metformin.
Proper blood glucose control
is important to prevent longterm complications of diabetes
such as damage to blood
vessels and nerves. Because of
Trulicity’s unique once-weekly
administration, it may be
preferred by patients who have
difficulty remembering to take
their current medication or
who want more flexibility.
Before taking Trulicity, it is
important to inform your doctor
of certain conditions. Tell your
provider if you have any history
of severe gastrointestinal (GI)
disease, thyroid cancer, or family
history of thyroid cancer. As
always, it’s important to let your
provider know of all prescription,
over-the-counter, and herbal
medications you are taking.
The Bottom Line
Trulicity offers a simple,
once-weekly way to control type
2 diabetes. This GLP-1 analog
acts in many ways to help achieve
glucose control and a healthier
self. Unlike other diabetes meds
on the market, Trulicity has little
risk of low blood sugar and may
even help with losing weight.
Trulicity really does equal
simplicity in the fight against
type 2 diabetes!
Submitted by:
Candis M. Morello, Pharm D, CDE, Associate
Dean for Student Affairs at UCSD Skaggs
School of Pharmacy and Pharmaceutical
Sciences, Clinical Pharmacist at VASDHS.
Brittany Newton, Third Year Student
Pharmacist at UCSD Skaggs School of
Pharmacy and Pharmaceutical Sciences.
Taking Control Of Your Diabetes
9
Living Well
Blackberry
Salad with
Pork
Recipe by:
Servings 2 (1 1⁄2 cups greens,
2 ounces cooked pork,
1⁄2 cup berries, and
2 tablespoons dressing each)
Carb. Per Serving 28 g
Prep 25 minutes
Roast 20 minutes
Stand 3 minutes
10 My TCOYD Newsletter, Vol. 52
1 5- to 6-ounce piece pork tenderloin
Salt
Black pepper
1⁄4 cup blackberries and/or raspberries
2 tablespoons lemon juice
1 -1⁄2 tablespoons olive oil
1-1⁄2 tablespoons honey
3 cups packaged mixed baby salad greens (spring mix)
1 cup blackberries and/or raspberries
1⁄2 cup grape tomatoes, halved
1 tablespoon pine nuts, toasted* (optional)
1. Preheat oven to 425°F. Place pork on a rack
in a shallow roasting pan. Sprinkle with a dash
each of salt and pepper. Roast, uncovered,
about 20 minutes or until an instant-read
thermometer inserted in center registers
145°F. Remove from oven. Cover roast with
foil and let stand for 3 minutes. Cool slightly.
Cut pork into 1⁄4-inch-thick slices.
2. For dressing, in a small food processor or
blender combine the 1⁄4 cup blackberries, the
lemon juice, oil, honey, and a dash each of salt
and black pepper. Cover and process or blend
until smooth. Strain dressing through a sieve;
discard seeds.
3. To serve, divide greens between two salad
bowls or serving plates. Divide the 1 cup
berries, the tomatoes, pine nuts (if using),
and pork slices between salads. Drizzle with
dressing. Serve immediately.
*Test Kitchen Tip: To toast pine nuts, place
them in a shallow baking pan. Bake in a 350°F
oven for 5 to 7 minutes, shaking pan once or
twice. Watch closely so nuts don’t burn.
Per serving: 283 cal., 13 g total fat
(2 g sat. fat), 46 mg chol., 147 mg sodium,
28 g carb. (7 g fiber, 20 g sugars), 18 g pro.
Exchanges: 0.5 vegetable, 0.5 fruit, 1 carb.,
2 lean meat, 2 fat.
Recipes from Diabetic Living, © Meredith Corporation. All rights reserved. Used with permission.
For more great recipes, visit DiabeticLivingOnline.com
Topic of the Month
Preventing
the Shark Attack
By Steven Edelman, MD
I
am 28 years old and have type 1 diabetes. I am
currently on an Animas insulin pump, as well as a
continuous glucose monitor. I also just got the Vibe
so I will not have to carry around my pump and CGM
monitor. I have had the hardest time preventing my
blood glucose values from spiking up well above
200mg/dl after eating. As you can see from my
Dexcom photo, it looks like a shark fin! I usually
get really urked and give myself a rage bolus, which
sometimes works fine and at other times may lead
to a hypo (see attached photo)!
Answer: This is a very common and frustrating
problem for insulin users, especially if you have
type 1. The insulin that you give via a pump or an
insulin pen is given in the fatty tissue below the
skin (subcutaneous tissue) and gets into your blood
stream way too slowly. This leads to the blood
glucose getting excessively high after eating since
the nutrients (especially rapid-acting carbohydrates)
get absorbed into the circulation a lot faster than
the insulin does. This leads to a mismatch between
the absorption of food and insulin action. There are
several things you can do to help avoid a shark attack.
1
Give yourself a pre-meal bolus of fast acting insulin
approximately 20-30 minutes before you actually eat.
You can give yourself about 30-40% of what you think
you will need for that meal and then the rest later. This
pre-bolus is called ‘priming the pump’. It has been shown
to really limit the post-meal shark fin spike. If you wear
a pump it is quite easy; however, if you are using an
insulin pen you will have to give yourself two injections
for the meal.
Try to limit the amount of rapid-acting carbohydrates
2
in your meal. This may be hard to do, but definitely
eliminate drinks with a lot of sugar calories, and no fruit!
Spread out your caloric intake as best you can. I know
3
this seems like a pain but eat slowly and, if you can, save
part of your meal for later as a snack. Mixing your rapidacting carbs with fat and protein can help as well.
Try Afrezza, the inhaled insulin that is now available.
4
It has a rapid-on rapid-off time course of action that
will not only limit how high your glucose goes after
eating, but also reduce your chances of having a delayed
hypoglycemic reaction. Please see the Edelman Report
on Afrezza on our website for more information.
Taking Control Of Your Diabetes
11
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Goofus and Gallant
(continued from page 2)
them because “he felt the same
whether he took them or not,” and
he read on the internet that statins
cause liver damage, memory loss,
and muscle aches.
Gallant also has type 1 diabetes
and doesn’t have an insulin pump
but instead, he takes multiple
daily injections of his long-acting
basal insulin (Levemir or insulin
detemir), as well as his pre-meal
fast-acting insulin (Humalog or
insulin lispro). He tests his blood
sugar level six to eight times a day
and is hoping to get insurance
12 My TCOYD Newsletter, Vol. 52
approval for a Dexcom CGM
device. Gallant struggles with the
daily ups and downs, but at least
his A1c is 6.8% with several mild
hypoglycemic reactions a week.
If you have type 1 diabetes,
are you more like Goofus or
Gallant?
I know these examples may
seem extreme to you but I see these
types of folks in clinic
every day! There is no
question that Goofus
wants to live a long and
healthy life but has many
misbeliefs and misaligned
priorities. He may have
fear, guilt, depression,
or just plain old lack of motivation
to take control of his diabetes.
As a caregiver, it is disheartening
and frustrating to see Goofus as a
patient, year after year with little
or no change. I rarely give up on
these folks because I know if you
continue to give support without
judgment, the Goofuses of the world
eventually do come around! For
me, I personally can only
relate to Gallant, as I am
perfect...hahaha!
Steven Edelman, MD
Founder and Director
Taking Control Of Your Diabetes