Conference Pearls

• Seventh Annual Diabetes Technology Meeting (San Francisco, October 25th - 27th)
• European Association for the Study of Diabetes (Amsterdam, September 17th-21st, 2007)
• American Association of Diabetes Educators (St. Louis, August 1st - 4th, 2007)
• Taking Control of Your Diabetes (Santa Clara, September 15th, 2007)

Seventh Annual Diabetes Technology Meeting (San Francisco, October 25th - 27th)

We will be back next issue with more from the Diabetes Technology meeting - in the meantime, we describe below our impression of the keynote talk from Dr. Richard Kahn, Chief Scientific and Medical Officer of the ADA.

To start, Dr. Kahn provided a fascinating history of diabetes care, highlighting that the cost and complexity of treating diabetes has increased. First there was only insulin. Then, in the 1950s/1960s, oral drugs were developed and diabetes care was no longer a simple proposition. In 1964, test strips came about, and in the 1970s the A1c test was invented. Our advisory board pointed out that the A1c test was actually invented in the 60s!! Since the 1970s there has been a "blizzard" of new discoveries, resulting in more data, risks, costs, and complexities. Kahn claimed the medical industry established enormous marketing budgets, "causing patients to clamor for the latest technology." Wow! What's that all about? Last time I checked, my diabetes equipment was helping me to live a far better, more healthy life, one that kept me out of emergency rooms and in the thick of life.

Dr. Kahn continued by explaining that new developments were often justified by trials he implied were sub-par. There were almost no limits or constraints to the use of new diabetes technology, he claimed. We would agree more evidence should be produced to show the value of technology; on the other hand, we also believe many trials are difficult to execute in a "real world" environment. It was surprising to us that Dr. Kahn didn't mention that patients do have fewer complications today than they did in the 1950s, that they live longer, and that they have, at least to some extent, a higher quality of life due to better blood glucose monitors, insulin delivery systems, and better, more stable drugs and better insulin.

By contrast, we thought Dr. David Klonoff said it best at the conference when he noted that decades ago, his waiting rooms were full of patients with the worst complications (amputations, blindness) and today, on average, he sees far fewer patients in the worst conditions. We certainly have a long way to go, but we credit diabetes technology as being instrumental in the developed world for reducing complications and hope that self-glucose monitoring in particular becomes much more widely available in developing countries so they can see these improvements too. We also hope more improvements are in store - to be sure, Dr. Kahn is right that outcomes must improve much further.

Per Dr. Kahn, as a result of new tools and complexities, the cost of healthcare in the US soared from a small percent of GDP in the 1970s to 16 percent of GDP in 2006 - this amounts to about $7,100 on healthcare per person per year. America does not get its money's worth, he said. Americans spend more per capita than in any other country, even though health outcomes lag behind many other countries. We would certainly agree that America is not the best health system globally in some respects - but largely it is reimbursement woes (absence of payments for education, for physician care, for drugs, and for technology) that need to be addressed. Specifically, the lack of payments to healthcare providers to work comprehensively with patients who are chronically ill is untenable in our view and we hope the ADA continues to advocate on behalf of better payments for healthcare providers - and better payments for drugs and devices to improve care and improve lives.

Diabetes care contributes significantly to America's healthcare costs. Dr. Kahn emphasized that diabetes costs Medicare a third of its entire budget. Self-monitoring costs taxpayers over $1 billion "even though there hasn't been a single randomized, control trial demonstrating benefit." In spite of tremendous spending, the quality of diabetes care in America leaves much to be desired, he said. As noted, we would certainly agree that the quality of diabetes care in the US could be dramatically improved but we would cite systemic problems as a bigger culprit than the cost of new technology. We believe that offering patients enabling technology such as blood glucose monitors, pumps, and continuous monitors will allow patients to better communicate with their healthcare providers and to learn to take the best care of themselves.

Looking to the future, Dr. Kahn believes that technology will need to bring simplicity rather than complexity, and will need to cut costs rather than increase costs. We certainly applaud Dr. Kahn's views on this front! As health care costs rise faster than inflation, accountability (value provided per dollar spent) becomes more important, he says. We absolutely agree with him on this point and believe most patients and healthcare providers would! As more health care costs are shifted to the patient, Dr. Kahn stressed that patients will begin wondering why new technologies increase costs rather than reduce costs, and the patient will begin looking for better value. In the future, diabetes technology will need to be more effective, timely, safer, patient centered, efficient, and equitable (these are so called "systems of care" improvements). We strongly support these goals - as well as the goal of reimbursement!

Compliance is certainly an issue. Today, Dr. Kahn said that over 70% of diabetes patients don't take their diabetes medications properly, and a technology that could improve patient compliance would improve outcomes tremendously. We also strongly agree with this. Technology should identify and reduce errors, rather than add ways to make errors. Technology that could improve patient adherence would be a tremendous breakthrough. Kahn also said that gadgets that add complexity would receive more scrutiny than gadgets that simplify diabetes care. Where we differ with Dr. Kahn is where he said that there would be a new equilibrium favoring improvements in systems of care advances as opposed to new fancy and expensive technology. We certainly believe medication adherence could and must be improved significantly - but not reimbursing new drugs and technology is not the way to get there - rather, we should think about what education is needed in tandem with what tools - this would differ by patient, of course. Dr. Kahn also didn't acknowledge that sometimes side effects are the reason people don't continue to take their medicine. Blaming that on the patient is counter-productive at best. Improving reimbursement for doctors and educators would be an excellent start to enhancing care. Diabetes is complicated and patients deserve more time with their healthcare professionals.

During Q&A, Dr. Kahn joked that the most cost effective solution in terms of healthcare expense would be to urge every American to begin smoking at age 15. This was not met with much appreciation from what we could tell - he clearly did not have the most welcoming audience, for obvious reasons. We know others also interpreted Dr. Kahn's words as saying diabetes technology wasn't really of value. We certainly hope we are wrong about that, for the sake of all of us that already have some reimbursement for tools - and for the sake of those that are still trying to garner reimbursement for valuable tools.

Overall, we are concerned that Dr. Kahn's views may become a platform and that they will have negative implications for pump and continuous glucose monitoring reimbursement in particular. We certainly believe the right evidence should be produced to demonstrate value of diabetes technology - we also think from a patient perspective it's unfortunate that one of the ADA's highest staff members made some statements that made some feel that technology like insulin pumps and continuous monitoring (and to some extent even self blood glucose monitoring) were threatened or shouldn't be valued. If that is the case, this shows very little, if any, value to patients, families, healthcare providers, payors, or average Americans. We look to ADA for leadership on these important fronts and hope that it will advocate for improved cost control and new products and technology and reimbursement for products and healthcare providers - then, we would feel we were moving in a very positive direction.

back to top

European Association for the Study of Diabetes (Amsterdam, September 17th-21st, 2007)

In September, the diaTribe team traveled to Amsterdam to attend the 43rd Annual Meeting of the European Association for the Study of Diabetes (EASD). This year, it attracted over 14,500 participants. Compared to its American counterpart, the annual meeting of the American Diabetes Association (ADA), EASD was most focused on basic science and insulin therapy. See below for our EASD Pearls.

The name of the game at EASD? Intensification. Whether discussing glycemic control, macrovascular events (heart attacks, strokes) prevention, or insulin initiation, presenters and chairs kept citing the need for faster, tighter, and more comprehensive diabetes management. Whew, this puts the pressure on us as patients! Some of the field's leading researchers called on all doctors and nurses to be more aggressive in fighting diabetes - change a diabetes management regimen before it fails, they say, and before inadequate management raises our risk of poor health outcomes. This means setting ambitious A1c goals, trying for better post-meal glucose control, and using combination therapy.

All things continuous! Continuous glucose information and continuous subcutaneous insulin infusion (CSII or insulin pumping) both yield better control and higher patient satisfaction. We would agree with this! Several presentations throughout the week suggested that continuous monitoring translates into better glucose management. Pumps also make for better glucose results, particularly in groups such as children, overweight individuals with type 2, and pregnant women with type 1. CSII is associated with less fear of hypoglycemia, less concern about diet restrictions, and higher treatment satisfaction despite the fact that researchers said pumps can be hard to figure out how to use (they call this the "complexity factor" - we are lobbying for more "user-settable" settings we can just all set personally so we can use and ignore features as we wish!).

Appropriately enough, given the theme of intensification, several talks at EASD predicted a trend toward more insulin therapy for type 2 patients. Insulin, no longer just the heavy-duty machinery for reigning in abnormal blood glucose, should be considered a "positive therapy" for positive results. Taking insulin earlier is associated with tighter glycemic control in the short-term and reduced rates of cardiovascular events and hypoglycemia in the long-term, in addition to improved micro- and macrovascular health. The need for providers to "get positive" (and become more persuasive with us, the patients!) on insulin therapy is clear. In-session surveys showed that attendees believe needle fear is the #1 reason patients do not want to start insulin. Hmm, do we agree with that as patients?! Furthermore, data on type 2 patient opinions show that few believe insulin will help them manage their diabetes better, and almost a third of physicians postpone insulin as long as possible. That's a problem! If your A1c is over 7 and you can't get it down, we suggest you talk to your doctor and ask if he or she would consider any changes if they were you! Some people believe the 7 percent A1c goal will go down and that we should be at more "normal" A1c levels, like Dr. Nancy Bohannon in San Francisco - so you might ask your doctor about that too.

More intensive management will require greater patient participation. To meet post-prandial glucose (PPG or after-meal glucose) targets, the International Diabetes Federation (IDF) recommends that people taking insulin should test three times a day, including one test at least two hours after a meal. These guidelines might affect people with prediabetes, too, since they are based on PPG. Shifting toward taking earlier insulin also places greater responsibility on patients, since insulin therapy requires patients to get some significant education on dosing, carb counting, and administration.

The Relationship between Insulin Sensitivity and Cardiovascular risk (RISC) trial results show widespread benefits of physical activity. More evidence that we have to get out and move! While exercise and lifestyle intervention were not central themes of the conference, impressive data from this trial suggest many benefits from all forms of physical activity. Total activity, not just intense exercise, improves insulin sensitivity, and increased activity is associated with improved insulin sensitivity independently of waist circumference. The bottom line is that moving during the day is extremely beneficial, irrespective of intensity.

Once again, when it comes to reducing cardiovascular risk, the best tactics involve intense treatment. Cardiovascular (CV) risk is best reduced through tight blood glucose control and intensive therapy, including early insulin initiation. The importance of glycemia in cardiovascular health is indisputable; 69 percent and 39 percent of patients admitted for acute myocardial infarction (MI or heart attack) or stroke test positive for impaired glucose tolerance (IGT) and undiagnosed type 2 diabetes, respectively. Furthermore, the most common risk factor for CV events in individuals less than 45 years is undiagnosed metabolic disorders and obesity. The American College of Cardiology is working on new guidelines that demand glucose testing before patients admitted to a hospital for acute cardiovascular conditions can be released.

Finally released, a new system for reporting blood glucose. Results from one trial looking at average blood glucose control and A1c have identified a new equation to make numerical assessments of glycemic control more accessible to patients. Researchers hope patients will find it easier to integrate this information into their management behaviors and improve control because the average glucose scale matches that of glucose meters. In a conversation with Dr. Zach Bloomgarden, reputed as one of the best, well-known diabetologists in New York, diaTribe learned that this new equation may not be universally applicable for all patients. Here's a rough idea of how A1c translates to meter readings:

6 percent = 126 mg/dl (7 mmol/L)
7 percent = 155 mg/dl (8.6 mmol/L)
8 percent = 182 mg/dl (10.1 mmol/L)
9 percent = 211 mg/dl (11.7 mmol/L)
10 percent = 239 mg/dl (13.3 mmol/L)

Greater attention must be given to depression in diabetes. The association between diabetes, depression, and adherence exposes the need for new mental health screening guidelines to support providers in identifying patients whose physical health cannot improve without attention to mental health.

back to top

American Association of Diabetes Educators (St. Louis, August 1st - 4th, 2007)

This year's AADE in August in St. Louis was extremely educational, as always. We tip our hats to the organizers for putting together an amazing faculty of speakers - especially for the well-attended general sessions that set the tone for four days of insights.

We applaud Former Arkansas Governor, Mike Huckabee's initiative in taking on diabetes and obesity, but we think he should also advocate that the government act directly. Mr. Huckabee argued that the government won't do anything until there's mass advocacy from the public, but we think it's going to have to be a more two-way process - patients will have to advocate, the government will have to take action, and it will (unfortunately) be an incremental process on both sides. In our view, the government should take a harder look at reforming food subsidies, for example subsidizing fruit and vegetables. It could also be more proactive in helping businesses and insurers realize that they'll be more efficient and pay less in the long term (for health costs) if they invest in preventive care.

"We don't have a health care system, we have a sick care system." We have a health crisis, which is leading to a health care crisis, and not vice versa. Because we are not focused on prevention, 80 percent of health care expenditures are spent on preventable chronic diseases, which are mostly due to overeating, under-exercising, and smoking. We spend more of our GDP on health care than any other country: 17 percent, compared with 10.5 percent in Switzerland, 9.5 percent for most European countries, and down from there.

Notably, pump and CGM expert, Dr. Bruce Bode, said that insurance companies were likely waiting to see hypoglycemia-related car accidents and comas before they think seriously about reimbursement for continuous glucose sensors. He added that not everybody shows marked improvement simply by using a CGM device. The STAR 1 trial showed that the best results are seen in patients who have A1c percentages already below 8 percent. In addition, preliminary results from one of his ongoing studies have shown the need for continued use of sensors in order to maintain improvements in A1c. That makes sense - we also understand that people who look at their CGM devices the most frequently do the best - that makes sense too! If you watch closely, you're more likely to make changes, of course, especially if you're on pump therapy and it seems likely if you make frequent small changes, that obviates the need to bigger changes and makes big big shifts less likely to be necessary.

If you have type 2 diabetes and your A1c is above 8 percent, Dr. Leahy says you need insulin and that if you take it, you'll feel better! Dr. Leahy, a noted endocrinologist from the University of Vermont, said it was great that insulin is now on the same line as second-line therapy in the ADA guidelines. There was applause when he said people need to be put on insulin earlier. He said that it is imperative that primary care physicians (PCPs) know how to put people on basal insulin " he said, "There's not enough of us, and many people are going to need it." Dr. Leahy said he would like to change stepped therapy, such that the first stage is one or two oral drugs, the second stage is basal insulin, and the third stage is basal insulin plus another insulin dose at the biggest meal. Dr. Leahy is also a "big believer" in Symlin, an anti-hyperglycemic drug reported to also help with weight loss in type 1s and insulin-dependent type 2s. As always talk to your physician before altering your therapy.

Dr. Leahy said he often lectures to PCPs. Responding to the prompt, "My biggest problem in starting insulin is:" the first answer from PCPs is always: "My patients won't do it" (other options are, "Not sure what to do," "Not sufficient time or support staff," and "Fear of weight gain or hypoglycemia"). The main problem PCPs say their patients cite is fear of injection. However, less than 50 percent of PCPs have ever ("once in their life") given a saline injection in the office. "It's daunting that they don't know these things." We personally believe that "physician resistance" might be just as big or bigger than "patient resistance" especially since some doctors don't think they have the time to teach insulin, given the reimbursement rates for education are almost nil!

To the nearly full hall, the highly-respected Dr. James Gavin of Emory University gave a well-received talk about diabetes outcome disparities among ethnic groups in the US. African Americans are 1.8 times as likely to have diabetes as whites (about 13 percent of African Americans have diabetes) and have 3-5 times the risk of lower-limb amputations, as well as increased risk of heart attack, kidney disease, and premature death. Minority groups have lower frequency of home-glucose testing than whites and less use of intensive insulin therapy. Solutions include culturally appropriate programs - this should not be "taken lightly" - that are economically feasible, with more aggressive insulin and combination therapy in minority groups.

There are real genetic differences among ethnicities, but the epidemic in high-risk minorities is mostly environment-driven. Our genes haven't changed in the last 30 years, but diabetes has tripled. Numerous barriers exist for improved outcomes: lack of awareness of the disease and its consequences, insufficient access to patient education, delayed diagnosis, living in a disadvantaged community, distrust of medical professionals, failure to treat early and aggressively, and the requirement of complex medical interventions (which means more time and resources) from the provider.

We need especially aggressive treatment for minorities. Dr. Gavin pointed out that the expert National Minority Quality Forum has recommended, given earlier disease onset among minorities, the greater need to attempt to alter the natural history of the disease and to use more intensive therapy with earlier combo therapy and with insulin. He emphasized that the National Diabetes Education Program (NDEP) is working to disseminate information about diabetes and encouraged health care providers to use and refer their patients to its resources.

The amazing diabetes advocate Dr. Francine Kaufman (Children's Hospital, Los Angeles) distinguished between type 1, type 2, and maturity onset diabetes of the young (MODY). In children, about 90 percent of diabetes is type 1, less than 10 percent is type 2, and only a small amount (1-3 percent) is MODY. Generally type 2 and monogenic (caused by a mutated single gene) diabetes are post-puberty diseases, although recently there has been a great increase in the number of pre-puberty cases of each. It is often difficult to differentiate type 1 from type 2 diabetes in overweight adolescents. Genetic testing is commercially available and should be considered for any child who fits the MODY diabetes profile - white, not obese, and does not have Acanthosis nigricans, a skin hyperpigmentation often found on the back of the neck or other body folds .

Puberty increases insulin resistance, even in normal weight children. Most children experience a 30 percent increase in insulin requirements during puberty. To date, 17.1 percent of children (age 2-17) are obese, and many of them already have high insulin resistance prior to puberty; this is a fast track to type 2 diabetes. The ratio of girls with diabetes to boys with diabetes is about 1.7 to 1.

Dr. Kaufman discussed the situation of type 1s who gain weight and develop type 2. This situation is growing more common, and Dr. Kauffman suggested that metformin should be considered in such cases. In one study of type 1s, metformin lowered A1cs by 0.6 percent and reduced the insulin dosage by about 20 percent. In another study, metformin had similar benefits, and additionally caused significant weight loss and lowered LDL cholesterol. More studies are required to investigate metformin treatment in type 1s.

Dr. Sanchez of the University of Texas School of Public Health delivered an interesting talk in which he spoke about the need for health reform and improvements in health literacy, especially among minorities. He called for better integration of public health and medical care as well as better prioritization and reimbursement of interventions that most efficiently optimize health. He was often interrupted by bursts of applause from the responsive 1,500+ member audience. He highlighted the need for health care reform to create patient-centered, primary care based, prevention-focused and community-oriented interventions. He stressed the need for better integration of public health and medical care since patients spend so little time in doctors' offices and so much time where they "earn, learn, buy, lie, pray, and play".

The health care industry needs to reexamine its priorities. While lauding the value of scientific research, Dr. Sanchez pointed out that getting people to quit smoking may be a more immediately effective tool for diabetes treatment than extended research into "beta blockers". He noted that if resources were diverted from biomedical research into education, diabetes patients would be in better position to control their disease or avoid it altogether. He cited statistics showing $31,300 spent per quality adjusted life year (QALY) for metformin as opposed to $1,100 per QALY for lifestyle intervention.

During pregnancy, women should have fasting blood sugar under 96 mg/dL (5.3 mmol), two-hour post-prandial blood glucose (PPG) <140 mg/dL (7.8 mmol), and overnight blood glucose of 65-135 mg/dl (3.6 to 7.5 mmol). Ideally, A1cs should be lowered before pregnancy to as close to normal as possible - pregnancy expert Dr. Lois Jovanovic recommends under 5.5 percent. Exercising when possible remains an important part of glucose control throughout pregnancy. Ketoacidosis (extreme hyperglycemia) can occur rapidly and at lower glucose levels during pregnancy. During the first trimester, morning sickness and food intolerance often contribute to what is called "maternal hypoglycemia". During the second and third trimesters, insulin resistance increases due to the high levels of many pregnancy-related hormones, and patients need more insulin, perhaps even triple or more what they needed pre-pregnancy. Insulin requirements drop back to normal levels or below normal levels after pregnancy, though nursing can cause more glycemic variability than usual as well.

Insulin is the "gold standard" for pregnancy for type 2 patients. Oral agents are not generally recommended for use during pregnancy. There have been no studies yet of Apidra, Lantus, or Levemir during pregnancy. Some studies have found that both insulin and glyburide are equally successful at any given level of fasting blood glucose. Recommendations published recently by the 5th International Workshop - Conference on Gestational Diabetes suggested that glyburide is a useful adjunct (additional therapy) to medical nutrition therapy and physical activity in women with gestational diabetes. Glyburide may be less successful in obese patients or those with marked hyperglycemia earlier in pregnancy. The same international body does not recommend metformin, Byetta, or Symlin for the management of diabetes during pregnancy as trials have not been done to determine safety.

It is easy to come up with a list of four or more cheap and safe medications patients should take daily - ask your healthcare team if a daily dose of the following is right for you: aspirin, an ACE inhibitor - for hypertension, a statin daily (probably, not absolutely), and antioxidants. Switching to a totally different category, it sounds like we're going to see a lot more about fish oils in the literature in the future, and it's something we should probably all talk to our doctors or educators about taking.

Mike Huckabee also noted: Change is possible, but it's going to take a generation. We need to first change attitude via awareness, and then change the environment, like better snacks in schools, walking paths, escalators that are turned off at least some of the time!. The action phase is when we get laws once new behavioral norms are in place. Note that this comes after societal changes - we can't legislate proactively or it will be a battle about personal rights. "Universal coverage is not as critical a goal as universal health," he said. "We can get to universal coverage if we want to, but the most important change to make is a change in culture." The solution is not as simple as laws, governing food in schools, for example - though, he added, these are good goals (he worked with President Clinton to get sugary soft drinks out of school cafeterias).

back to top

Taking Control of Your Diabetes (Santa Clara, September 15th, 2007)

The Taking Control of Your Diabetes (TCOYD) Conference was held on September 15th 2007, in Santa Clara, CA. From Hawaii to Minneapolis, our very own advisory board member, Dr. Edelman and his team hold about a dozen TCOYD meetings every year - the biggest one in San Diego (on December 8 this year). The Santa Clara meeting was labeled by diabetes veterans as providing "reestablished focus in a positive and affirming way" while neophytes said they "learned more today than (they) ever knew was available." About 1500 people attended and most break-out sessions were filled to capacity.

Dr. Edelman lamented the statistic that 92 percent of Europeans were using insulin pens compared to only 12 percent in the U.S., saying, "If you are not using a pen, you are in the dark ages." Sadly we also realized this while attending the EASD conference - many more type 2 patients in Europe take insulin at all, for a start!

Still on devices, he described continuous glucose monitoring as the biggest advance in type 1 diabetes therapy since the discovery of insulin. It provides an important step toward the artificial pancreas for diabetes. Stem cell research/gene therapy, however, could also provide a potential cure one day he says. Dr. Edelman himself has type 1 and we always listen closely to everything he says about diabetes since we know he has an extra incentive to be in the loop!

He ended his presentation on a poignant quote from Larry Verity, an exercise physiologist: "If you cannot find time for exercise, you will have to find time for disease." He recommended yearly dilated eye exams (retinopathy) , cholesterol panels (LDL, HDL and triglycerides), and regular visits to the dentist (tooth and gum disease).

Dr. Polonsky's presentation was aptly titled "Psychological Secrets for Effective Self-Management." The bottom-line message was that diabetes is tough and it is not inhuman to make mistakes - give yourself a break! At diaTribe, we know as well as you do how important it is to find a balance between managing diabetes intensively and having a life outside of diabetes.

Dr. Polonsky likened diabetes management to a job that involved a lot of work, with minimal vacation time and pretty bad pay - boy can we relate to that! He emphasized that diabetes was not a death sentence and elegantly corrected the notion that diabetes is the leading cause of blindness, amputation, and kidney failure. He pointed out that it is poorly controlled diabetes that causes these complications. "Well controlled diabetes is the leading cause of nothing." He quoted Sir William Osler, who is reputed to have said, "The easiest way to live well is to develop a chronic disease and take good care of yourself." In Joslin's 50-year Medalist Study of groups of people who were diagnosed with diabetes 50-60, 60-69 or >70 years ago, researchers suggest that individuals with such long duration of type 1 diabetes may be protected from, or show slower progression to, diabetic retinopathy. The study showed that about 50 percent of the 50-60 year diabetic duration had retinopathy - 44 percent and 27 percent respectively for the 60-69 and >70 years of diabetes. Almost 50 percent of all groups had no significant microvascular complications. These statistics strongly support the idea that a diabetes diagnosis is not necessarily a prediction of severe complications.

Dr. Polonsky described the use of smaller plates as a creative way to monitor and control food intake. He added that focusing on other things - like television - while eating often leads to mindless over-eating. Additionally, it is important to make healthy foods easily accessible and keep the junk stashed away - if not out of the house completely. Learn more about his practice at the Behavioral Diabetes Institute.

Ruth Spirakis, a CDE and dietitian, advised diabetes patients to spread carbohydrate intake throughout the day - we know this will help us avoid spikes, though it's hard to schedule! She emphasized moderation over elimination (okay, good - we weren't considering elimination anyway!) and urged patients to ask for low-fat or whole grain substitutions while eating out. Check out UConn's Rate Your Plate game.

Dr. Wargon drew attention to the need for proper foot care for patients. He recommended a foot check on every doctor's visit, checking shoes before wearing them, and avoiding home remedies and "bathroom surgery" for foot problems. Read more on ADA guidelines to foot care.

back to top