diabetes FAQ: general (part 1 of 5)
Edward Reid
Posting-Frequency: biweekly
Last-modified: 5 August 2002 (excludes change list and Table of Contents)
Changes: more gastroparesis info from JKD (4 June)
change all @ to (AT) (17 June)
add pointer to NLD mailing list (18 June)
change maintainer's address to use SpamCop address (22 June)
add other conversions (5 Aug)
------------------------------
Subject: READ THIS FIRST
Copyright 1993-2002 by Edward Reid. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.
Advice given in m.h.d is *never* medical advice. That includes this FAQ.
Never substitute advice from the net for a physician's care. Diabetes is a
critical health topic and you should always consult your physician or
personally understand the ramifications before taking any therapeutic action
based on advice found here or elsewhere on the net.
------------------------------
Subject: Table of Contents
INTRODUCTION (found in all parts)
READ THIS FIRST
Table of Contents
GENERAL (found in part 1)
Where's the FAQ?
What's this newsgroup like?
Abuse of the newsgroup
The newsgroup charter
Newsgroup posting guidelines
What is glucose? What does "bG" mean?
What are mmol/L? How do I convert between mmol/L and mg/dl?
What is c-peptide? What do c-peptide levels mean?
What's type 1 and type 2 diabetes?
Is it OK to discuss diabetes insipidus here? What is it?
How about discussing hypoglycemia?
Helping with the diagnosis (DM or hypoglycemia) and waiting
Exercise and insulin
BLOOD GLUCOSE MONITORING (found in part 2)
How accurate is my meter?
Ouch! The cost of blood glucose measurement strips hurts my wallet!
What do meters cost?
Comparing blood glucose meters
How can I download data from my meter?
I've heard of a non-invasive bG meter -- the Dream Beam?
What's HbA1c and what's it mean?
Why is interpreting HbA1c values tricky?
Who determined the HbA1c reaction rates and the consequences?
HbA1c by mail
Why is my morning bg high? What are dawn phenomenon, rebound,
and Somogyi effect?
TREATMENT (found in part 3)
My diabetic father isn't taking care of himself. What can I do?
Managing adolescence, including the adult forms
So-and-so eats sugar! Isn't that poison for diabetics?
Insulin nomenclature
What is Humalog / LysPro / lispro / ultrafast insulin?
Travelling with insulin
Injectors: Syringe and lancet reuse and disposal
Injectors: Pens
Injectors: Jets
Insulin pumps
Type 1 cures -- beta cell implants
Type 1 cures -- pancreas transplants
Type 2 cures -- barely a dream
What's a glycemic index? How can I get a GI table for foods?
Should I take a chromium supplement?
I beat my wife! (and other aspects of hypoglycemia) (not yet written)
Does falling blood glucose feel like hypoglycemia?
Alcohol and diabetes
Necrobiosis lipoidica diabeticorum
Has anybody heard of frozen shoulder (adhesive capsulitis)?
Gastroparesis
Extreme insulin resistance
What is pycnogenol? Where and how is it sold?
What claims do the sales pitches make for pycnogenol?
What's the real published scientific knowledge about pycnogenol?
How reliable is the literature cited by the pycnogenol ads?
What's the bottom line on pycnogenol?
Pycnogenol references
SOURCES (found in part 4)
Online resources: diabetes-related newsgroups
Online resources: diabetes-related mailing lists
Online resources: commercial services
Online resources: FTP
Online resources: World Wide Web
Online resources: other
Where can I mail order XYZ?
How can I contact the American Diabetes Association (ADA) ?
How can I contact the Juvenile Diabetes Foundation (JDF) ?
How can I contact the British Diabetic Association (BDA) ?
How can I contact the Canadian Diabetes Association (CDA) ?
What about diabetes organizations outside North America?
How can I contact the United Network for Organ Sharing (UNOS)?
Could you recommend some good reading?
Could you recommend some good magazines?
RESEARCH (found in part 5)
What is the DCCT? What are the results?
More details about the DCCT
DCCT philosophy: what did it really show?
IN CLOSING (found in all parts)
Who did this?
------------------------------
Subject: Where's the FAQ?
This FAQ attempts to answer the questions which have been most frequently
asked in misc.health.diabetes (m.h.d). This is not a complete informational
posting. My only criterion for inclusion is that the topic has frequently
appeared in m.h.d, either by an explicit question, or implicitly by posting a
related question or a common misconception.
This FAQ is posted biweekly to the Usenet newsgroup misc.health.diabetes.
If you obtained this article by some method other than reading Usenet,
refer to the section on "Online resources: diabetes-related newsgroups"
for brief information on how to obtain access to Usenet newsgroups and
misc.health.diabetes in particular.
Feel free to make copies of this FAQ for your personal use or for a friend or
relative, including to share with health care providers. If you want to make
this FAQ available to others on an ongoing basis (for example, on a BBS),
please do *not* post or copy the entire FAQ. Instead, post only this section,
entitled "Where's the FAQ?". This will enable others always to retrieve the
most recent version.
An informational posting on insulin pumps is posted to m.h.d at the same time
as this FAQ. See below for retrieval information. It was developed and is
maintained by Jim Summers <summers(AT)cs.utah.edu>.
An informational posting on diabetes-related software is posted to m.h.d at
the same time as this FAQ. See below for retrieval information. It was
developed and is maintained by Michael Wolfe <mwolfe(AT)wvnvms.wvnet.edu>.
I've used ideas and information from many people in writing this FAQ. With a
few exceptions I haven't attempted to identify them, but I thank them all.
The words herein are mine unless otherwise credited.
If you read this and it helps you, please let me know what part helped, and
why. If you read this and can't find what you want, let me know that too.
Such comments will help me decide what is worth working on, and whether.
You'd be surprised how little feedback I get. If you are reading this on the
newsgroup, just reply to this article. If you found this on the web, send
email to <edwar...@spamcop.net>.
These documents -- the FAQ, the insulin pump discussion, and the software
overview -- are available from the news.answers archives at rtfm.mit.edu.
Using anonymous ftp, get the files:
/pub/faqs/diabetes/faq/part1
/pub/faqs/diabetes/faq/part2
/pub/faqs/diabetes/faq/part3
/pub/faqs/diabetes/faq/part4
/pub/faqs/diabetes/faq/part5
/pub/faqs/diabetes/insulin-pump-disc
/pub/faqs/diabetes/software
or in web browser format:
ftp://rtfm.mit.edu/pub/faqs/diabetes/
If your net access is by email only, send an email message to
mail-server(AT)rtfm.mit.edu, subject ignored, body containing:
send faqs/diabetes/faq/part1
send faqs/diabetes/faq/part2
send faqs/diabetes/faq/part3
send faqs/diabetes/faq/part4
send faqs/diabetes/faq/part5
send faqs/diabetes/insulin-pump-disc
send faqs/diabetes/software
If you are using the World Wide Web, you can reach a WWW-formatted version of
the FAQ and other documents via the URL
http://www.faqs.org/faqs/diabetes/
You can also retrieve the plain text by FTP from the rtfm.mit.edu site
mentioned above, which has long been the most reliable source. However,
it only offers the simplest retrieval capability.
------------------------------
Subject: What's this newsgroup like?
Posting topics range through emotional support, treatment techniques,
psychological factors, health care practices, and insurance. We talk about
our problems, frustrations, depressions and complications to find out how
others handle the same issues and for mutual support. The atmosphere is
generally a highly supportive one, and most participants believe strongly
that this is an important aspect. As in other parts of the net, there are one
or two regular participants who believe that it is important to question the
motives and/or knowledge of anyone posting a new problem. If you find that
the first response is antagonistic, please wait a few hours. Every
antagonistic response will elicit a dozen sympathetic responses.
Meta-topics include discussions of how to best convey health information on
the Usenet, ethical treatment of other participants, what topics and
information are appropriate for m.h.d, where to find diabetes information,
and what the newsgroup should be like.
Betsy Butler says eloquently:
The positive posts of people who are in great control are very
motivating, but it is also helpful to hear from people who don't find
it so easy. I'm sure there are a lot of people who struggle to keep
control. The people who are having trouble also need to know that there
are others who struggle, and that they are not alone. It can be very
intimidating, and a blow to self-esteem for people to suggest that if
you would just do X, Y and Z, you will be in control. There are 100s of
factors to balance, and I think people need to be reassured that "yes,
it's hard to balance so many things, many of which can't be measured or
that don't act predictably."
Topics closely related to diabetes mellitus which do not have their own place
in Usenet are welcome. Examples are diabetes insipidus, hypoglycemia, glucose
intolerance, legal and employment ramifications of chronic illness, effects
on family members, how family members can best provide support, and so on.
misc.health.diabetes tends to be inclusive of anyone who needs it.
The same caveat applies here as in all newsgroups: the advice is worth what
you paid for it. This applies in spades to a critical health topic such as
diabetes. Never substitute informal advice for a physician's care. Advice
given in m.h.d is *never* medical advice.
The variety of individual responses to diabetes is exceeded only by the
variety of individual responses to life. No two patients respond alike, and
many respond *very* differently from others. These differences are
physiological, not just psychological. They reflect not only varying
responses, but the fact that diabetes itself probably has many causes, many
more than the few types currently recognized (see section on types). When you
read advice, realize that what works (or doesn't work) for someone else may
not work (or may work) for you. When you give advice, try to remember that
most advice is relative to the individual, not absolute. Recognize that you
can't treat your own diabetes by a set of rules, but only by knowing how your
own individual body and physiology work and by adjusting to your own
mechanisms.
------------------------------
Subject: Abuse of the newsgroup
As mentioned above, a few participants believe that name-calling and abusive
language are more effective than polite discussion, support and interchange
of information. They are wrong, and the vast majority of participants support
a more civilized and polite view of humanity. Since misc.health.diabetes is
unmoderated, we all have to live together.
A few m.h.d. participants have received abusive email. Some are afraid to
expose such abuse, having been told that email must always be private.
However, abusive email is no more deserving of privacy than obscene phone
calls or threatening letters. There is no authority to which you can report
abusive email (unless it contains an actual threat, in which can you may be
justified in contacting a law enforcement agency). Steve Kirchoefer
<swkirch(AT)chrisco.nrl.navy.mil> is willing to try to mediate problems with
email. Though Steve has no official authority, he has experience in dealing
with problems on the net and may be able to help clear up such problems. Send
him complete copies of any abusive email.
------------------------------
Subject: The newsgroup charter
The actual charter which led to the creation of the newsgroup in May 1993
follows. This charter was proposed by Steve Kirchoefer
<swkirch(AT)chrisco.nrl.navy.mil> and approved by a public vote of the Usenet
readership, and is the official statement of the scope and purpose of this
newsgroup.
1. The purpose of misc.health.diabetes is to provide a forum for the
discussion of issues pertaining to diabetes management, i.e.: diet,
activities, medicine schedules, blood glucose control, exercise, medical
breakthroughs, etc. This group addresses the issues of management of
both Type I (insulin dependent) and Type II (non-insulin dependent)
diabetes. Both technical discussions and general support discussions
relevant to diabetes are welcome.
2. Postings to misc.health.diabetes are intended to be for discussion
purposes only, and are in no way to be construed as medical advice.
Diabetes is a serious medical condition requiring direct supervision
by a primary health care physician.
------------------------------
Subject: Newsgroup posting guidelines
The following posting guidelines were adopted by a vote of m.h.d participants
in September 1994.
Posting guidelines for misc.health.diabetes:
Postings to misc.health.diabetes should be compliant with the standards
for all material posted to Usenet. The following articles may be found
in news.announce.newusers, and should be reviewed by all posters:
-Emily Postnews Answers Your Questions on Netiquette
-Answers to Frequently Asked Questions about Usenet
-A Primer on How to Work With the Usenet Community
-Rules for posting to Usenet
-What is Usenet?
Posting to misc.health.diabetes should be compliant with the group charter,
[which is in the previous section].
In addition to the above, the following guidelines are emphasized as
particularly relevant for contributions to misc.health.diabetes:
-No personal attacks or insults. Avoid argumentative debates. Responses
should concentrate on the issues presented.
-No private discussions. Take private discussions to email. When in
doubt, use email.
-Edit responses to avoid unnecessary inclusions of earlier postings.
-Edit subject lines as necessary to remain consistent with the topic.
-Support factual statements with your sources. If you can not recall the
source, then say so. Do not imply authority which you can not actually
support.
Additional information can be found in the general FAQ posted periodically
to this group.
------------------------------
Subject: What is glucose? What does "bG" mean?
Glucose is a specific form of sugar, one of the simplest. It is the form
found in the bloodstream. "Blood sugar" always refers to blood glucose, and
is abbreviated bG. All bG meters are specific for glucose and will not
respond to other sugars, such as fructose, sucrose, maltose and lactose.
Although sucrose (table sugar) is the most common sugar in food, glucose is
also common. Most fruits, fruit juices, and soft drinks contain large amounts
of glucose, and many foods contain small amounts. This means that you must be
very careful to clean any food residue from your fingers before drawing blood
for a bG check. Since the normal level of bG is only 1g/L (=100mg/dl), it
only takes a tiny speck of glucose on your finger to contaminate the sample
and give you a falsely high reading. 10 *micrograms* of glucose could raise
the reading enough to cause you to overreact dangerously.
------------------------------
Subject: What are mg/dl and mmol/l? How to convert? Glucose? Cholesterol?
There are two main main methods of describing concentrations: by weight, and
by molecular count. Weights are in grams, molecular counts in moles. (If you
really want to know, a mole is 6.23*10^23 molecules.) In both cases, the unit
is usually modified by milli- or micro- or other prefix, and is always "per"
some volume, often a liter.
This means that the conversion factor depends on the molecular weight of the
substance in question.
mmol/l is millimoles/liter, and is the world standard unit for measuring
glucose in blood. Specifically, it is the designated SI (Systeme
International) unit. "World standard", of course, means that mmol/L is used
everywhere in the world except in the US. A mole is about 6*10^23 molecules;
if you want more detail, take a chemistry course.
mg/dl (milligrams/deciliter) is the traditional unit for measuring bG (blood
glucose). All scientific journals are moving quickly toward using mmol/L
exclusively. mg/dl won't disappear soon, and some journals now use mmol/L as
the primary unit but quote mg/dl in parentheses, reflecting the large base of
health care providers and researchers (not to mention patients) who are
already familiar with mg/dl.
Since m.h.d is an international newsgroup, it's polite to quote both figures
when you can. Most discussions take place using mg/dl, and no one really
expects you to pull out your calculator to compose your article. However, if
you don't quote both units, it's inevitable that many readers will have to
pull out their calculators to read it.
Many meters now have a switch that allows you to change between units.
Sometimes it's a physical switch, and sometimes it's an option that you can
set.
To convert mmol/l of glucose to mg/dl, multiply by 18.
To convert mg/dl of glucose to mmol/l, divide by 18 or multiply by 0.055.
These factors are specific for glucose, because they depend on the mass
of one molecule (the molecular weight). The conversion factors are
different for other substances (see below).
And remember that reflectance meters have a some error margin due to
both intrinsic limitations and environmental factors, and that plasma
readings are 15% higher than whole blood (as of 2002 most meters are
calibrated to give plasma readings, thus matching lab readings, but this
is a recent development), and that capillary blood is different from
venous blood when it's changing, as after a meal. So round off to make
values easier to comprehend and don't sweat the hundredths place. For
example, 4.3 mmol/l converts to 77.4 mg/dl but should probably be quoted
as 75 or 80. Similarly, 150 mg/dl converts to 8.3333... mmol/l but 8.3
is a reasonable quote, and even just 8 would usually convey the meaning.
Actually, a table might be more useful than the raw conversion factor, since
we usually talk in approximations anyway.
mmol/l mg/dl interpretation
------ ----- --------------
2.0 35 extremely low, danger of unconsciousness
3.0 55 low, marginal insulin reaction
4.0 75 slightly low, first symptoms of lethargy etc.
5.5 100 Mecca
5 - 6 90-110 normal preprandial in nondiabetics
8.0 150 normal postprandial in nondiabetics
10.0 180 maximum postprandial in nondiabetics
11.0 200
15.0 270 a little high to very high depending on patient
16.5 300
20.0 360 getting up there
22 400 max mg/dl for some meters and strips
33 600 high danger of severe electrolyte imbalance
Preprandial = before meal
Postprandial = after meal
More conversions:
To convert mmol/l of HDL or LDL cholesterol to mg/dl, multiply by 39.
To convert mg/dl of HDL or LDL cholesterol to mmol/l, divide by 39.
To convert mmol/l of triglycerides to mg/dl, multiply by 89.
To convert mg/dl of triglycerides to mmol/l, divide by 89.
To convert umol (micromoles) /l of creatinine to mg/dl, divide by 88.
To convert mg/dl of creatinine to umol/l, multiply by 88.
------------------------------
Subject: What is c-peptide? What do c-peptide levels mean?
Thanks to Andrew Torres <andym(AT)ku.edu> for this section.
C-peptide blood levels can indicate whether or not a person is producing
insulin and roughly how much.
Insulin is initially synthesized in the form of proinsulin. In this form the
alpha and beta chains of active insulin are linked by a third polypeptide
chain called the connecting peptide, or c-peptide, for short. Because both
insulin and c-peptide molecules are secreted, for every molecule of insulin
in the blood, there is one of c-peptide. Therefore, levels of c-peptide in
the blood can be measured and used as an indicator of insulin production in
those cases where exogenous insulin (from injection) is present and mixed
with endogenous insulin (that produced by the body) a situation that would
make meaningless a measurement of insulin itself. The c-peptide test can also
be used to help assess if high blood glucose is due to reduced insulin
production or to reduced glucose intake by the cells.
There is little or no c-peptide in blood of type 1 diabetics, and c-peptide
levels in type 2 diabetics can be reduced or normal. The concentrations of
c-peptide in non-diabetics are on the order of 0.5-3.0 ng/ml.
------------------------------
Subject: What's type 1 and type 2 diabetes, and gestational diabetes?
The term diabetes mellitus comes from Greek words for "flow" and "honey",
referring to the excess urinary flow that occurs when diabetes is untreated,
and to the sugar in that urine.
Diabetes mellitus (DM) comes in the following classifications (which some
will argue don't really represent the actual types very well):
type 1 -- characterized by total destruction of the insulin-producing beta
cells, probably by an autoimmune reaction. Onset is most common
in childhood, thus the common (but now deprecated) term
"juvenile-onset", but the onset up to age 40 is not uncommon and
can even occur later. Patients are susceptible to DKA (diabetic
ketoacidosis). There seems to be some genetic tendency, but the
genetic situation is unclear. Most patients are lean. Always
requires treatment by insulin. Not sex-linked. Also referred to
as IDDM (insulin dependent diabetes mellitus).
type 2 -- characterized by insulin resistance despite adequate insulin
production. A large majority of patients are overweight at onset,
and a majority are female. Most are over 40, hence the common
(but now deprecated) terms "adult-onset" or "maturity-onset", but
onset can occur at any age. Patients are not susceptible to DKA
(diabetic ketoacidosis). There is a strong genetic tendency, but
not simple inheritance. Depending on the individual, treatment
may be by diet, exercise, weight loss, oral drugs which stimulate
the release of insulin, or insulin injections -- and usually a
combination of several of these. Also referred to as NIDDM (non
insulin dependent diabetes mellitus) *even when treated with
insulin* -- a confusing terminology which, unfortunately, is
supported by the ADA.
gestational -- occurs in about 3% of all pregnancies as a result of
insulin antagonists secreted by the placenta. It is recommended
that all pregnant women receive a screening glucose tolerance
test (GTT) between the 24th and 28th weeks of pregnancy to detect
gestational diabetes early if it occurs, as diabetes can cause
serious difficulties in pregnancy. Sometimes requires insulin
treatment. Not susceptible to DKA (diabetic ketoacidosis).
Usually disappears after childbirth, but about 40% of patients
develop type 2 diabetes within five years. Most authorities state
that the typical patient is female ...
malnutrition-related -- severe malnutrition sometimes causes diabetes --
hyperglycemia and all the usual symptoms. The reason is unknown,
and since this syndrome occurs almost entirely in third world
countries, research on this form of diabetes is nearly nonexistent.
other types -- sometimes called secondary. A catchall for forms not covered
by the types described above. Causes include loss of the entire
pancreas (to trauma, cancer, alcohol abuse, or exposure to
chemicals), diseases that destroy the beta cells, certain
hormonal syndromes, drugs that interfere with insulin secretion
or action, and some rare genetic conditions.
These terms are not used entirely consistently. Some doctors will refer to
any diabetic using insulin as type 1, and will refer to the early onset of
type 1 diabetes as type 2 until insulin therapy is required. This usage does
not fit with most modern usage as described above (type 1 is beta cell
destruction, type 2 is insulin resistance). The situation is complicated by
the fact that early in the course of the disease it can be difficult to
determine which type is occuring, especially for patients in their 30's, the
age when the onset of both types is common.
Different patients respond very differently to what is categorized above as
the same disease. The root causes of all forms of diabetes are not
understood, and are likely more complex and varied than the simple categories
show. Type 1 diabetes likely has a few root causes, and type 2 diabetes
probably has a larger number of root causes.
There are also well documented reports of cases of diabetes with unexplained
combinations of syndromes from types 1 and 2. These are sometimes referred to
as "type 1-1/2", and the reasons are not understood.
The classification above is not completely standard, and other classifications
exist.
About 90% of diabetes patients are type 2 (some 12 million in the US), and
about 10% are type 1 (some 1 million in the US). Discussion on m.h.d tends to
run about 2/3 type 1, I'd guess. This probably reflects the fact that type 1
diabetes is harder to ignore, and that type 2 seldom strikes the younger
people who are more likely to have net access. Type 2 is *not* less serious.
"1" and "2" are often written in Roman numerals: type I, type II. Because
typography is often unclear on computer terminals, I've stuck with the Arabic
numeral version.
Diabetes accounts for about 5% of all health care costs in the US, some
US$90 billion per year.
------------------------------
Subject: Is it OK to discuss diabetes insipidus here? What is it?
Diabetes insipidus (DI) results from abnormalities in the production or
use (two main types) of the hormone arginine vasopressin. The main
symptoms are excessive thirst and massive urination. The excess urine
flow is devoid of sugar. There are no blood glucose abnormalities, and
in fact there is nothing in common with diabetes mellitus except the
excess urination when untreated.
Diabetes insipidus caused by failure to produce vasopressin. This is
known as neurogenic DI (or central DI, or pituitary DI). It can be
treated with hormone replacement (by nasal spray or other routes). DI
caused by failure to use vasopressin (nephrogenic DI) is more difficult
to treat, but several drugs are available which help.
DI is much less common than diabetes mellitus, though a few people have
discussed it on misc.health.diabetes and are reading m.h.d. Such
participation is certainly welcome, but because the number of DI
patients is only 1 or 2 per 10,000 population (25,000-50,000 in the
US), there probably isn't a critical mass for discussion on Usenet.
I'm aware of two organizations which offer support specifically
related to DI.
DIARD publishes a support newsletter, maintains a support network,
distributes information on DI, and promotes education and research
related to DI, and has a web page with information and links:
Diabetes Insipidus and Related Diseases Network
535 Echo Court
Saline, MI 48176-1270
USA
+1 734 944 0078
email: GSMAYES(AT)aol.com
web: http://members.aol.com/ruudh/dipage1.htm
The DI Foundation publishes a quarterly newsletter, Endless Water,
promotes public awareness and understanding of DI, and provides
informational material to patients, medical practitioners and
researchers:
The Diabetes Insipidus Foundation, Inc.
4533 Ridge Drive
Baltimore, MD 21229
USA
+1 410 247 3953
email: diabetesinsipidus(AT)maxInter.net
web: http://diabetesinsipidus.maxInter.net
------------------------------
Subject: How about discussing hypoglycemia?
Sure ...
To clarify: the term "hypoglycemia" is used to refer to two distinct
conditions. The word just means "low blood glucose". This can occur as
an insulin reaction, the result of too much injected insulin (taken to
treat diabetes) compared to food intake and exercise. But low blood
glucose can also be a chronic condition resulting from abnormalities of
insulin secretion, and this chronic condition is also called
hypoglycemia.
Chronic hypoglycemia may be caused by beta cells which overreact to an
increase in blood glucose (bg) by releasing too much insulin, which
then causes a too-rapid drop in bG. Such a condition, called reactive
hypoglycemia, is usually handled by dietary adjustments, in particular
avoiding refined sugars and large meals which stimulate the
overreaction. This often requires an effort in calculating the diet and
monitoring bG levels that is equal to what anyone with diabetes needs.
Tumors (insulinomas) can cause a steady overproduction of insulin.
These generally require surgical removal.
There are other causes as well. Mayer Davidson discusses some in his
book _Diabetes Mellitus: Diagnosis and Treatment_. But you'll have to
find the Second Edition, because he dropped this chapter from the Third
Edition. I don't believe anyone claims to understand all the causes of
hypoglycemia. The US NIDDK has a booklet online which discusses some of
the less common causes:
http://www.niddk.nih.gov/health/diabetes/pubs/hypo/hypo.htm
So chronic hypoglycemia is closely related to diabetes mellitus in
being a disorder of insulin production and use, and requires many of
the same techniques for its treatment. The two are a natural for
discussion in the same newsgroup. Which is good, since there really
isn't anywhere else in Usenet at present to discuss chronic
hypoglycemia. Welcome.
A hypoglycemia mailing list, HYPO-L, is available and sees moderate
traffic. See the section on mailing lists in part 4 of this FAQ for
subscription information.
Lars Idema maintains a hypoglycemia FAQ and information on a variety of
hypoglycemia resources on the Internet. See his web page at
------------------------------
Subject: Helping with the diagnosis (DM or hypoglycemia) and waiting
Diagnosis of marginal type 2 diabetes, and even more so of
hypoglycemia, can be an iffy task. Single-point blood glucose
measurements often miss significant readings, especially for
hypoglycemia. While I don't recommend self-diagnosis, you can take some
steps on your own to aid your health care team in your diagnosis and
treatment. These are safe and useful steps. The first is purely
monitoring and not treatment or diagnosis on your part. The others are
good advice for anyone who does not have some other medical condition
to contraindicate the action, and are particularly good for those with
type 2 diabetes.
1) Get a blood glucose meter and start checking your blood glucose
before meals and at bedtime. Keep records. Also note what you ate, any
exercise, any unusual stress. If you suspect type 2 diabetes, also try
to check an hour after eating. If you suspect hypoglycemia, check any
time you have suspicious symptoms; you may also want to set up a few
runs where you check every 15-30 minutes for up to five hours after
eating.
Don't try to make any adjustments based on the readings until you review
them with your doctor -- just keep the record and show it to the
doctor. This will give the doctor more information than any examination
or lab test can give. Furthermore, if you are waiting for an
appointment, this record will put you ahead of the game when you
actually see the doctor. (If during this monitoring you see a dramatic
rise in blood glucose, to preprandial levels of 250 mg/dl [15 mmol/L]
and above, call the doctors and say you need an appointment *now*, not
in a month, not next week, and quote your bg levels.)
As an additional advantage, doing this monitoring on your own will
demonstrate to the doctor that you are willing to put in this kind of
effort. Often doctors are reluctant to ask patients to put in serious
time to monitor their health because so many patients don't follow up.
Blood glucose meters and all the supplies are OTC items. (True in the
USA, and I haven't heard of any country with a different policy.)
However, depending on where you live and what type of insurance or
national medical coverage you have, you may have to pay from your own
pocket if you do not have a prescription or proper pre-authorization.
For a month or so of monitoring, this is probably worth the cost.
2) Increase your exercise level, within levels that are safe in light
of any other medical conditions. In other words, if you are not already
in an exercise program, consult your doctor. Exercise will also help
with other stresses you are under. This is primarily applicable if you
suspect type 2 diabetes, but may help with hypoglycemia also.
3) Improve your diet if you are not already watching it carefully. A
standard diet with moderate calories and fat is good at this stage,
until you see the specialist. If you suspect hypoglycemia, you may want
to be especially careful of eating large amounts at one time, and avoid
concentrated sugars.
------------------------------
Subject: Exercise and insulin
Charles Coughran <ccoughran(AT)ucsd.edu> contributed this section.
The best way to deal with problems associated with diabetes and exercise
begins with understanding of what goes on in the metabolic system of
normal people and what the differences are for diabetics. Only with
such understanding can you make intelligent choices about
pharmacological tactics. Relying on rules of thumb can cause more
problems it solves because of the wide variability of individual
responses and the wide variety of diseases that fall under the rubric
of diabetes. Not to mention, I have seen postings where the rules of
thumb were clearly misunderstood.
While the following is intended for those who take insulin, it may
assist those on oral medications as well. Exercise in this context
means extended aerobic activity, say a minimum of 20 minutes of
jogging. This is a somewhat simplified account but I think it captures
the most important aspects for exercise related bg control. Comments
encouraged.
When a normal person starts to exercise, the insulin output of his
pancreas goes down. At first blush, this seems backward since the
muscles are working hard and therefore require more glucose to be
transported from the blood into the cells. There are two reasons more
glucose can be transported with less available insulin. The first is
that during exercise insulin becomes much more efficient. The mechanism
of this effect is not fully understood, but it helps overcomes the
reduction in circulating insulin.
Second, exercise activates non-insulin mediated glucose transport
pathways. These pathways are not sufficient to handle the load in the
absence of insulin, but do increase the effective insulin efficiency.
When insulin levels decline relative to the counterregulatory hormones
-- glucagon, epinephrine, norepinephrine, growth hormone, and cortisol
-- the liver is stimulated to release stored glucose. The blood glucose
that is being transported into the cells is replaced by that from
hepatic stores. It is this hormonal balance system that keeps the
levels of blood glucose in the normal narrow range during exercise.
For those of us who inject insulin, the first problem is obvious. Our
circulating levels of insulin do not react to exercise. Absent any
correction, when the muscles demand glucose and insulin becomes more
efficient our blood glucose plummets and we become hypoglycemic. This
is the reason for a commonly encountered prohibition to not schedule
exercise when your insulin is peaking. The higher the level of
circulating insulin, the more pronounced the effect.
One solution is to reduce our circulating insulin levels by reducing
insulin intake. Here specific advice starts to be difficult due to the
wide variety of insulins, regimens, and individual variability. The
spectrum spans from a Type II who takes a little NPH to help his beta
cells out to a c-peptide free pumper. I have spoken to diabetic runners
whose tactics would put me in an ambulance, even though our situations
seem to be very similar. You see a lot of advice of the form, "reduce
your insulin 2 units for every hour of strenuous exercise". This kind
of advice ignores real world variability and is sometimes much worse
than useless.
Clearly, someone who takes one shot/day has a much more limited ability
to adjust circulating insulin levels than someone using multiple
injections or a pump.
The other approach is to increase blood glucose levels by eating
carbohydrates timed to arrive at the blood stream in the form of
glucose when it is needed. The easiest way to do that is usually to eat
fast acting carbohydrates during or immediately preceding exercise.
Again, there are rules of thumb around about so many grams of
carbohydrates for a particular length of exercise at some defined
level. Again, they seem to be swamped by individual and circumstantial
variability.
Some of us do a combination of both and pump up our bg levels somewhat
before exercise and reduce insulin levels to keep things on an even
keel.
The bottom line is to make careful adjustments and test, and test, and
test, to find out how things work for your particular body.
So much for too much insulin. What happens when the circulating insulin
level is too low? When levels are so low that even the increase in
insulin efficiency doesn't overcome the defect, glucose isn't
transported into the cells. Worse, since insulin levels are low the
liver continues to pump glucose into the blood. The result is bg levels
rise with exercise. The muscles get stressed due to lack of fuel and
the metabolism of fats kicks in, ketones start being produced and the
danger of ketosis or ketoacidosis looms. This is the basis for another
rule of thumb which is often misunderstood. The rule is usually stated
"don't exercise when your bg is above 240 mg/dl (13.3 mmol/l) and
ketones are present in the urine". This makes sense because those are
signs that you have inadequate insulin supplies -- that's how many of
us got diagnosed. Exercise in those circumstances will make things
worse, not better. On the other hand, if you are 300 mg/dl (16.7
mmol/l) because you just drank a large regular cola by mistake with
lunch, exercise is a great way to bring that bg down in a hurry. Why
your bg is elevated is just as important as the fact of the elevated
level when deciding whether or not exercise is contraindicated. The 240
is also a somewhat arbitrary number. Some people start throwing ketones
at significantly lower levels.
In short: avoid exercise if your insulin level is too low. Do exercise
if you are sure your insulin level is adequate but your blood glucose
is too high.
Exercise also produces effects at longer time scales. Sometime after
exercise, there is often a take up of blood glucose by the muscles to
replenish depleted stores. This most often occurs an hour or two after
exercise, but has been reported in the range of 1/2 hour to 48 hours.
Again, as is the case during exercise, artificially high insulin levels
will lead to hypoglycemia. The last rule of thumb is to watch for
hypoglycemia after exercise.
*SPECULATION BEGINS HERE* A problem some of us encounter from time to
time is a post exercise bg spike. Blood glucose readings will be
reasonable after exercise but sharply elevated a few hours later. It is
my speculation that this represents circulating insulin levels that
were adequate to deal with exercise induced blood glucose demand with
its attendant insulin efficiency increase, but too low to deal with the
post exercise demand when insulin efficiency has lowered somewhat. It
has been my experience that post exercise elevated bg levels respond to
much less insulin than would be required in a more normal situation. It
appears that insulin efficiency falls off after exercise at some rate
and you can be on the correct side of the curve during exercise and the
wrong side after. This hypothesis is the best of a couple I have come
up with. *SPECULATION ENDS HERE*
Regular exercise over time scales of weeks or months can reduce overall
insulin requirements. In addition, as muscles become trained and
improve their internal storage, it feeds back into the amount of
glucose demand present during exercise, and thus into the entire
control cycle.
Diabetes makes exercise, and almost everything else, harder. But, hey,
if it was easy it wouldn't be any fun :-)
There are two very good, readable books from which you can get more
information. The better is Campaigne and Lampman, _Exercise in the
Clinical Management of Diabetes_. Almost as good is _The Health
Professional's Guide to Diabetes and Exercise_ edited by Ruderman and
Devlin and published by the American Diabetes Association.
------------------------------
Subject: Who did this?
--
Edward Reid <edwar...@spamcop.net>
Tallahassee FL
Michael D. Wolfe
Posting-Frequency: monthly
Last-modified: 24 Aug 99
Information Technology Resources to Support Persons
Involved with Diabetes
Copyright 1994,1995, 1996, 1997, 1998, 1999 by Michael Wolfe. Re-use beyond
the fair use
provisions of copyright law and convention requires the author's permission.
New since last posting: Updates to Software for Psion PDA
Introduction
Apology.
This review is described as "incredibly outdated" by Rick Mendosa
(http://www.mendosa.com), not without reason. It was maintained with care
before the Web, when the Usenet was one of the main places where the pre-Web
Internet community gathered. Since the Web, it has been maintained
sporadically.
Even when regularly maintained, my emphasis was to be as inclusive as
possible, and to add the new programs that were appearing monthly. I never
re-checked the information regularly, and, as Mr. Mendosa points out on his
site, many of the programs listed here are no longer available.
He apparently tried to contact all the sources I listed, and found many of
the 800 numbers disconnected, and many of the vendors of 1997 out of business.
Current vendors of software for diabetes, and providers of freeware, can
generally be found via any of the major search engines on the Web, so this
faq remains mainly for historical reasons, to let people know about Vic Abell
and others, who made an excellent program available for free via ftp when the
first meters appeared with memory and download capabilities.
The world has changed a lot since I first wrote this faq: Lifescan started
charging those who wanted to use the download feature, the market seems to
have turned toward the simpler meters that don't support downloads and
computer analysis of recorded blood sugar readings, and many insurance
programs will not reimburse members for meters and strips capable of
recording and downloading this information.
This faq represented a lot of effort by many people over several years, and I
am open to suggestions for how it can continue to serve the diabetic
community.
The old faq continues below.
There are now many information technology products that can help with
diabetes management. These include a variety of software and other on-line
information resources. Software is now available for meal planning and
information recording. In addition, for users of meters with memory and
download features, there is now software that can automatically download
readings and display them in more informative ways than the usual logbook.
Most of this review is about these programs to download data from Touch II
meters; however, I have started to add information about other software, as
well as other on-line information sources, both commercial providers and the
Internet. So far, I have found one FTP site and several Web sites.
I also mention America Online and CompuServe. I haven't had time to check the
other commercial information providers, but Prodigy and some of the other
providers also have some resources to aid with diabetes management..
Basically, then, this article is divided into three parts:
I. Software to download and analyze blood glucose readings from home
monitoring devices
II. Other software (nutritional databases, logbooks, etc.)
III. Other Electronic Information Resources (FTP, Web, commercial sources)
Acknowledgements: Vic Abell gets special mention for his help, as does
Jo Anne Jacques who sent in two programs I haven't seen anywhere
else. Biostore corporation and Medmaster donated copies of their
commercial software. Thanks also to Ed Reid who sent me a number of
programs to review and helped me get started with this review.
I. Software to download and analyze blood glucose readings from home
monitoring devices
Many authors have written software (of varying degrees of sophistication) to
help with home diabetes management. The programs are available for many
machines and many operating systems. Most programs started out as what I
would call "Electronic Logbooks," i.e., record-keeping programs which require
users to type into their PC all the info that was formerly written in a paper
Logbook, including their blood glucose levels insulin, meals, exercise, etc.
Another class of program, however, uses meters with memory and serial output
ports to allow users to record the information on their meter and later
download it for analysis. Today, the two are converging, with the older
logbooks getting download features, and the older downloading programs
proving users the capability of entering other relevant data. Many of these
programs may be found on America Online and CompuServe. Searching for more
programs on these services is discussed at the end of this review. At least
two programs are available for free over the Internet (one, Touch 2, works on
both DOS machines and on UNIX machines, and the other, BloodPlot works on the
Macintosh). In addition, the manufacturers of the memory meters generally
sell programs for their meters.
This section covers only those packages that will download data from a meter.
Note that some are intended to be used in physician's offices, while others
are aimed at the home users. A few are intended to be used in a form of
client/server (abuse of term?) mode, in which the patient's program downloads
data from the meter and transmits the information to the physician over some
telecommunication channel, while the physician's program keeps a database of
all patient information, analyzes it, and presents the data to the physician
in a variety of online formats.
I have a tendency to judge the programs based on my own needs, which is to
download data from my meter as easily as possible and present it in a
paper-based form acceptable to my (computer illiterate) diabetologist.
The programs are grouped as follows:
Section A are programs for the Lifescan Touch2 meter
Section B are programs that download data from other meters.
Most these programs run in DOS or Windows on a standard PC, but Eric Jensen
has
written a freeware program for the Macintosh in MacPerl.
On DOS or Windows machines, IRQ conflict problems are the most common reason
why a program won't work. The Touch2 distribution by Vic Abell
(ftp://vic.cc.purdue.edu/pub/touch2.zip) explains what to do. Also, Biostore
has offered to help people with this problem if they call. Comment: I believe
the above is quite out of date now. Operating Systems have improved, and
Biostore is no longer marketed.
The programs are reviewed below.
------------------
Section A. Software for the Lifescan One Touch meters
Note: to download data from a One Touch meter it is necessary to obtain a
cable from Lifescan. The cable is proprietary (it is not just an RS232.) The
cable is $5.00 + two UPC codes from Lifescan strips in the U.S. Other
Lifescan country offices have their own policies. To get the cable, U.S.
users must call the 800 number on their meter and request a special order
form. Lifescan US was unable to explain the policies outside the U.S. but
posts to misc.health.diabetes indicate that the cable may be hard (or at
least very expensive) to obtain outside the U.S., and no one has had any luck
in replicating it.
For non-U.S. readers, if your local Lifescan office charges more than $5.00
for the cable, you still MUST get the cable to use the download feature (I
suggest trying to get a friend in the US to get the cable for you).
This section is organized as follows: Part 1 is for DOS, Part 2 is for
Windows, and Part 3 is for the Macintosh.
Part I. DOS Based Programs
1. UTILITY, the Lifescan-provided utility software
Cost: varies by country. $5.00 in the U.S. to purchasers of One Touch strips.
This was the most accessible program: In 1995 Lifescan provided this program
at no cost to U.S. users who have purchased the cable by calling their 800
number on the back of the meter (1-800-227-8862 US; 1-800-663-5521 Canada).
The Lifescan offices in each country are independent, and some charged (an
exorbitant amount) for the cable and software, while others (including the
U.S. office) first made them available for free, then for $5.00 to users of
Lifescan strips (exclusive users of clone strips are now precluded from using
the download features). Some country offices will also send a copy of the
program at no charge. It only took me about two weeks to get the cable, but
it took me about six weeks to get the software since it was out of stock and
had to be backordered. Other people report receiving the software rather
quickly, then having to wait for the cable. Lifescan has been changing its
policy, so this information is only valid as of February, 1995.
This software is no longer offered by Lifescan.
Requirements: A PC running DOS.
Review: This program downloads a One Touch or Touch 2 meter to a PC. It does
not perform any analysis or graphing. The manual suggests that the data may
be analyzed with a spreadsheet and shows how the data looks when opened into
Microsoft Excel for Windows. Details on how to do this are not provided in
the manual. This is a very basic program, but may be all that some people
need. The downloaded data can be imported into some of the electronic
logbooks available.
One advantage to this program is that it works for most meter settings, since
it does not try to analyze the data. The user need know nothing about COM
ports or BAUD rates, the program automatically selects the correct settings.
It may not work if the language has been changed to anything other than
English or Spanish, and will not work if the meter has been used with the old
Lifescan Datamanager until the communications settings have been reset to the
factory settings. For most users, it will work with no problems, except for
printing. Instructions for printing have a typo, they should say:
PRINT/D:LPT1, (the manual says PRINT D:/LPT1, which is wrong).
In any case, users MUST call the number on the back of their meter, obtain
and fill out the form from Lifescan, and order the cable. After obtaining the
cable, the software may be included at no extra charge (Lifescan wasn't
clear on this).
2. TOUCH2 by Vic Abell
Recommended. An excellent freeware program.
Cost: freeware
Available as described below by the author.
> My MS-DOS program, called TOUCH2, will possibly do what you want.
> It is available via anonymous ftp from vic.cc.purdue.edu
[and ftp.demon.co.uk] in
> pub/touch2.zip [or t2117.zip or touch2.tar.gz or t2117.tar.gz]
>
> If you do not have ftp access, you can get a copy of a TOUCH2
> distribution file by email by sending an email letter to:
>
> ftp...@decwrl.dec.com
>
> In the body of the letter put:
>
> reply <your_email_address>
> connect vic.cc.purdue.edu anonymous <your_email_address>
> chunksize 100000
> binary
> uuencode
> get /pub/touch2.zip
> quit
> > If you want touch2.tar.Z instead, put its name in place of touch2.zip >
in the "get" directive. If you want btoa encoding instead of > uuencoding,
replace the "uuencode" line with "btoa".
>
> CAUTION: <your_email_address> MUST be RFC822-compliant -- e.g.,
> a...@cc.purdue.edu or 99999...@CompuServe.COM.
>
>
> Vic Abell <a...@cc.purdue.edu>
>
The program is also available on CompuServe, in the Diabetes forum. It may be
accessed by typing
GO DIABETES
Library: 9
Download: Touch2.zip
Requirements: Any IBM compatible with a serial port and 128K memory (and,
of course, the Lifescan cable).
Review:
For those of you familiar with the old TOUCH2, there is a new and much
improved version, 1.17, which was released in May 1995. The new version, like
the old one, is very easy to use. It downloads the data from the meter and
displays both the numeric glucose levels and a graph. It provides average
blood sugar readings, as well as average checkstrip and control readings. It
also allows users to set all the adjustments on their meters from their PC,
e.g., to turn the beep on or off, set for US or metric readings, etc.
Readings can now be partitioned by time of day or by event code. In other
words, the program will now plot separate graphs for fasting, lunch, dinner,
and bedtime values. This feature was labelled "essential" by my doctor. The
latest edition allows values to be plotted in chronological order (previous
edition only allowed reverse chronological order.)
I had no trouble at all downloading and installing with ftp (but was unable
to get my mailer to read the uuencoded ftpmail version). Printing the graph
is done with DOS characters, so it provides the basic information, but does
not look as attractive as a more sophisticated graphics program. Users
wishing nice graphs can import the data into a graphics package. For
programmers, source code is available, so any desired feature can be added by
anyone with a C compiler. One drawback is that users must have ftp and
pkware, and know how to use them. Users without ftp access to the Internet
must have a good email package. This is "freeware", so limited support is
available, although Mr. Abell gave me quite a bit of help via email. He also
includes his phone number with the program, but I haven't called him.
Finally, as Mr. Abell says, this is not a finished, polished product. It does
everything I need, but is a bit more awkward to use than some of the
commercial or shareware packages. One big plus to the program is that source
is distributed, so programmers can add any features they need. Also, the
program is free and readily available to anyone on the Internet. Finally, it
does provide, in a somewhat unattractive but perfectly usable format, all the
information my diabetologist needs.
Other Requirements:
For someone with ftp access, the zip file mentioned above requires PKUNZIP
version 2 or later. For someone without ftp access, the ftpmail version
arrives uuencoded in two parts. My mail package (Pegasus) cannot handle
two-part uuencoded files, so I was unable to use the ftpmailed version.
Basically, anyone who must use ftpmail is dependent on having a good email
package on their system. Vic Abell sent me a number of suggestions that I
tried to get the mailed version to work, for which I thank him; however, none
of them worked with my email package. There is also a Unix (R) tar version.
The diabetic community owes Vic Abell a debt of thanks for writing this
program and making it freely available. This program was developed before the
UTILITY program mentioned above, and, with the latest enhancements, provides
"for free" the essentials available in the shareware and commercial programs
listed below. While support is limited, Mr. Abell has been very helpful via
email. The documentation included has one of the most lucid explanations I
have seen of IRQ problems and how to solve them.
---------------
Aside: the above instructions for getting touch2 from vic.cc.purdue.edu apply
to getting software from ftp.demon.co.uk, as well as other ftp sites.
---------------
3. OTVIEW by Merritt Island Technologies
This program is shareware
Cost: $25.00, if downloaded, $29.00 if disk is ordered by mail, $30.45
if ordered by credit card.
Available for downloading from ftp.demon.co.uk, Compuserve, and many local
bulletin boards, including their own SPACECON BBS (407) 459-0969. More
information can be obtained by writing to Tom.Mc...@mit.com or to TOM
MCKEEVER MERRITT ISLAND TECHNOLOGIES, INC. 253 MERRITT SQUARE, SUITE 616
MERRITT ISLAND, FL 32952
4. Blood Glucose Monitor Version 1.1
This program is shareware.
Cost: "No specific amount will be charged by the author." People who need the
program and can't afford it are allowed to use if for free. "ALL OTHERS ARE
EXPECTED TO PAY an amount that indicates the degree of usefulness they
believe this program offers."
Available for downloading from Compuserve Diabetes Forum or
from
Norman E. Shimmel
1015 Bonniebrook Road
Butler, PA 16001
70043...@compuserve.com
Phone: (412) 283-2723
No longer available, according to Mr. Mendosa. Certainly, the old compuserve
address is out of date.
5. Glucose
Cost: Freeware to individuals; nominal charge if used in a clinic setting
Contact: WTD
23399 Duffield RD
Cleveland, OH 44122
wx...@cwru.edu
Features: Reads data from OneTouch II and Profile meters; Plots results; Runs
in DOS from a floppy disk (can be run from hard disk if desired)
Requirements: 286 or better with 640K of memory, plus the Lifescan Cable
Review: Excellent, if basic, free program that downloads and plots
results from a One Touch meter. It also handles AccuCheck meters with
the auxiliary BMC.EXE program. It's small, light, and works.
Part 2. Windows Software
Note: While I had no trouble downloading data with any of the DOS programs,
all the Windows programs had problems with my Pentium. The fix is explained
below:
=========Windows / Pentium Problem =============
This was a problem with the early versions of Windows and the first Pentium
processors. The solution was first discovered and forwarded to me by
Biostore, for use with any software. This hasn't been a problem for many
years.
I recently noticed, since being upgraded from a 486 to a Pentium, that all
the Windows-based download programs are crashing, some on the second attempt
to download, others on the first. Many people have trouble downloading if
their meter is connected to COM3 or COM4 due to IRQ conflicts. The
commercial companies, Medmaster and Biostore, are aware of the
Pentium/Windows problem. New drivers for the serial port are supposed to fix
it. The Microsoft Knowledge Base, available from the Internet
http://www.microsoft.com, America Online, and Compuserve has a new driver,
serial.386 that fixes the problem for Windows for Workgroups. Biostore has
been making the other driver, comm.386 for Windows, available as well.
Medmaster now has a version that bypasses the drivers. Biostore suggests the
following work-around
A bug exists in Pentium machines using the PCI bus. The bug involves the
16550
UART chip. The bug affects serial communications in Windows 3.1 and Windows
for WG. We have drivers that fix the problem.
The WinWG driver was supplied by
Microsoft and the Win 3.1 was provided by Gateway but will work on all
machines. If someone would like to supply me a place to upload these
drivers
to, we'll make them available to anyone (BioStore customers or not). An
interim workaround involves changing the [386 Enh] section of System.ini to
include the following line:
COMxFIFO=0
Replace x with the COM port you are using for meter communications (i.e.
COM2FIFO=0)
T.J. De Pietro
BioStore International Inc.
805-250-9709
New Twist: Balance PC is set to run on a Pentium, and may have trouble
on a 386 or 486SX.
============================End Windows / Pentium Problem ========
2A. Freeware/Shareware Programs
1. Diabetics Assistant version 2.0 by Douglas Williams
This program is shareware. I recommend using a commercial program, rather
than this one, at this time.
Cost: $30.00
Available for downloading from America Online, Compuserve, or by writing
Douglas A. Williams
13725 174th Ave NE
Redmond, WA 98052
This is also available on ftp.demon.co.uk in 3 zip files.
Requirements:
Windows 3.1, Dos 3.3 or later, 286 (???) processor, 2 MD RAM, 2.5 MB free hard
drive space, mouse or other pointing device. These are the official
requirements. I recommend at least a fast 386 or 486.
Review: This is a Windows-based point and click program. The new version
supports international date formats and units, and also allows the user to
track medication. The meter can now be configured from the program.
For those who read my earlier review, all the problems to which I alluded
in that review have been corrected, but a new bug has crept in.
The program will take the data and produce a facsimile of a normal (i.e.
paper)
logbook for users who prefer the old-style data display. Some doctors prefer
this format, and this program allows users to check their blood with their One
Touch, then generate the log book just before their scheduled visit to the
doctor. The logbook will have readings for
fasting, noon, dinner, and bedtime. Unfortunately, the new version will not
print the logbook. An error in the print routines causes a HP printer to
eject hundreds of blank, or nearly blank, pages.
Color 3-D graphs, as well as line graphs, are also available, but, again,
these do not print well.
The user can use the meter event codes for fasting, normal, bedtime, etc.
The program can then graph each event code separately.
This is shareware, and some users may experience difficulty.
It is a little more difficult to install than the commercial programs or the
DOS programs, and the fact that it is shareware becomes obvious as
bugs appear. In addition, the user must still understand the SHARE utility.
It is also very slightly more difficult than the commercial packages (or the
DOS program Touch 2) to select separate types of readings (fasting, noon,
etc.): the user must define these as codes, ensure the codes are entered
into the meter when the reading is taken, and filter based on the codes. I
don't find this a problem, but some of the other programs make this even
easier (e.g., button driven on the main screen).
My own experience was that, fifteen minutes before my scheduled appointment
with my doctor, I tried to download the readings from my meter, and the
program
crashed my PC. The problem is that my PC was set up with SHARE installed using
the defaults. The installation manual (who reads these things?) warns that
Diabetics Assistant requires that SHARE be installed with /L:500. Again, this
is shareware, so users must carefully read the install manual. Once properly
installed, the program will track blood glucose on the monitor, but will not
print an acceptable version of the data.
Ian Preece has posted a much more extensive (and more favorable) review to
ftp.demon.co.uk.
(Thanks to Ed Reid for sending me a copy of version 1 to review.)
2. Diabass
Shareware, 79.- DM + 20.- DM for shipping/handling in the EEC.
Pricing and handling in other countries may be obtained for
oliver...@uni-konstanz.de
Snailmail:
Oliver Ebert
Postfach 100 501
D-78405 Konstanz
Germany
Tel und Fax: +49 (7531) 171 22
This program is designed to support diabetics with a wide variety of meters
operating in English or German with American or European units.
It has the help tips that Microsoft customers have come to expect.
It has support for Accu-Chek, Accutrend, and One Touch meters, as well
as support for import from such programs as Diabetic's Assistant, PC-Link
MelliSys, MelliComp, and several others.
The program estimates Ha1c, and provides the option of recording information
obtained from each visit with the user's physician.
When I tried it with my One Touch Profile, it only downloaded 43/250 readings.
On my Touch 2, it only downloaded 100/250 readings.
The capabilities and flexibility of the program with regard to language,
meters, and units is quite extensive; my only reservation is that I had
problems getting it to work correctly.
3. Diabetic's Meter Utility
Cost: Freeware
Availability: download from http://www.public.asu.edu/~mpatt/dmumain.html
Written by: Michael Patterson
(many thanks Michael)
Features: Reads a touch2 or profile meter. Runs in Windows. Can be run from a
floppy. Generates very nice graphs, and is very easy to use.
Requirements:Any PC with Windows 3.1, 95, or NT, Lifescan Interface cable.
Review: An excellent Windows freeware program for downloading and graphing
from a Touch II or Profile meter. Easy to use, worked for me
"out of the box."
2B. Commercial Programs
While the commercial programs provide a few more features than the
shareware or freeware programs listed above, the biggest advantage is to
the new user. Commercial programs are fully supported, with friendly staff
who don't mind helping absolute novices. Both Biostore and Medmaster have
been extremely helpful with any problems that I had.
1. Biostore Pro
Cost: $79.95 + $4.00 S&H
Call 1-800-435-1992 (orders)
1-805-250-9709 (information only)
This replaces the program Biostore L. I do not have a copy available for
review at this time. However, I would like to mention that
Biostore has been extremely helpful providing support for users, and that
the previous version was well worth the (lower) price.
They did mail me a crippled version, but it self-destructed before I had
time to review it. They have since mailed me another crippled version,
but I haven't had the time to try to review it.
2. Medmaster
Cost $79 (includes S&H)
Call 1-800-455-4GSC
Installation: The software arrives on disks which must be unprotected. The
installation disks are not copy protected, and the manual advises making a
backup. Installation follows the usual Windows protocol: run a:setup from the
program manager in Windows. As with Biostore, I had some trouble, but the
support staff were very helpful. They have developed a version that does
not use the defective Windows drivers. It is still in beta; however, for
users of 386 machines, the current version should work.
This program started out in section 2 as a sophisticated logbook in which
users could record exercise, meals, and insulin and plot the impact of each.
With the addition of the download feature, it appears to be a very powerful
and full-featured program. The program allows the user to track all food eaten
(with help to tranlate from food items to exchanges), to track insulin taken
(and different types for those who mix), to track exercise taken (with
translations from an activity to calories consumed), as well as downloading
blood glucose readings. The idea is to develop a model for blood sugar levels
as a function of insulin, food, and exercise.
It provides excellent statistics and data for a physician who uses a PC;
however, I found that printing out the data is limited to a single month
at a time, and requires more time than I care to spend.
3. Diastats 2.0
Cost $29.95 + 3.50 S&H
Call 1-800-252-7492
or write
Orchard Enterprises
P.O. Box 847
La Miranda, CA 90637
Review: Not available at this time.
4. Level
Cost: $79.00 (includes shipping and handling)
Call: 1-800-682-9375 or write
HealthWare
P.O. Box 5396
Buena Park, CA 90620
System Requirements: Windows 3.0 (3.1 recommended), IBM or compatible 286
or above. If the software is to be used with a Touch II meter, the
user must obtain the LifeScan cable (mentioned above) to use with the
meter. Cabling requirements for other meters are not known at this time.
Features: Downloads data from LifeScan One Touch II. The company hopes to
have software for other meters at some point.
Review: Not available at this time. A demo version will be sent to anyone
calling the 800 number, but I do not have a full version available to
review. The demo version crashed my (admittedly fragile) machine.
5. Mellitus Manager
Cost: $79.95 + $5.00 S&H Total $84.95
Contact: EuMedix, Inc.
P. O. Box 720278
San Diego, CA 92172-0278
Credit Card Orders: You may order with MC, Visa, Amex, or Discover through
Public Software Library by calling (800) 2424-PSL (ORDERS ONLY).
Request Product # 11254 (Mellitus Manager)
TECHNICAL SUPPORT TOLL FREE 800-455-4105
Website: http://www.metamedix.com/mellitus_manager.htm
Features: Downloads data from Touch 2 meters, MediSense, and Accu-Check and
displays results as graphs, logbooks, or summary statistics.
Requirements: Windows, 386 or better, 4MB RAM, 1.9 MB disk space,
Lifescan cable.
Install Program: Mellitus Manager writes quite a few files to the
Windows System Directory; however, it also has an Uninstall program
to get rid of them.
Review: This is one of the few programs that allowed me, 1/2 hour before
my quarterly visit to the diabetologist, to install the program out
of the box, download and print out my data in logbook format. For users who
wish to take their blood sugars regularly, download them occasionally, and
print the results in a format which is "diabetologist friendly," this program
comes closest to being ideal.
It also includes the ability to manually enter glucose, insulin, food
eaten, and exercise. It has the provision to automatically
track sick days, stress, ketones, physician visits, eye and foot exams,
bloodwork, and hypos.
Its main attraction, at least to me, is the extreme ease of installation
and use.
Version 4 has a lot of help for the new user, as well as clinic support
and individual support.
Bill Eastman
(beas...@austin.rr.com http://home.austin.rr.com/beastman) reports that this
program works with Accu-Chek Advantage and with MiniMed 507 and MiniMed 507C
pumps.
6. Glucostat v2.0
Cost: $65
Contact: Glucoware
P. O. Box 43369
Cleveland, OH 44143-0369
Phone: (216) 460-1051
email: 75053...@compuserve.com
Requirements: 80386 CPU or better, Windows 3.x, 8MB RAM recommended,
10 MB disk space, mouse.
Main features: A monitoring program for recording and graphing all aspects
of diabetic life. Two types of insulin, meals
(text description), and glucose levels.
Installation: Beginning with this program (I won't reinstall all the
others) I will note how well behaved the program is. Glucostat writes
quite a number of files to \windows\system, which could be a problem; it
also writes to \windows\msapps. Current thinking is that this should be
avoided by applications. This does not mean that Glucostat is any worse
than other programs reviewed here, as I just began this caveat--an
uninstaller will be needed to remove Glucostat if one should decide to do
so. Many of the other programs have this problem, so it isn't really
fair to criticize Glucostat alone, but this information will be
included in all future reviews.
Review: This program is off to a very good start. It provides a
fairly good interface for downloading data from a meter, and
lots of tables and charts. It also has extensive electronic
logbook features for meals, exercise, insulin, etc.
It works best if the user sets event codes for breakfast, lunch, dinner
and snacktimes. Otherwise, it uses times of day.
I say it is off to a good start because it seems to have been developed on a
very large screen monitor with a resolution of at least 800 X 600, and not
really tested for usability on a standard size monitor---i.e., the buttons and
instructions were a little inconveniently placed on my 640 X 480
monitor.
Likewise, the graphs, while very nice, printed on two pages rather
than fitting themselves to a page. This is distracting for pie
charts. This problem can be fixed by properly setting up the printer,
but it does not automatically adjust based on the printer configuration
stored in Windows.
The program graphs histograms (frequency of each blood sugar
reading), 30 and 90 day graphs.
It does a table of readings sorted by breakfast, lunch, dinner and
snacktime.
It has modem upload and download features, and works with a variety
of meters (I can only test with the touch2 at this time, so I
don't really know how well it works with other meters.)
Overall, I think this could develop into an excellent commercial
product.
7. In Touch, by Johnson and Johnson
Phone: the 1-800 number on your meter. US 1-800-227-8862
Cost: $69 + 1 boxtop, or $89
Systems: Windows, only
Requirements: Windows 3.1 or 95, 386 required, 486 recommended.
Review: Originally, Johnson & Johnson gave away meters, cables and software
in order to sell their strips; then, the strip was cloned, so they now
either charge and/or require boxtops from their strips. In the case
of their DOS software, a boxtop suffices; in the case of the Windows
version, $69 + boxtops are required. Since this column is currently
unsupported, I can't really review the software unless they send me
a review copy. The mother of one of the programmers wrote to me to
say that it is a very good product, and I have no reason to doubt her;
however, I have not seen the product at this time.
8. Balance PC
Cost: $59.95, available in phamacies
Contact: MediLife, Inc.,
30 Monument Square
Concord MA 01742
Toll Free: 1-888-656-5656
Features: Lifestyle interview and suggestions, food database, reports,
downloading of "leading" meters. Multimedia lessons on diabetes management.
Internet access package. Multiple-users database. Video on usage.
Requirements:Windows (3.1, 3.11, WFW) or Windows 95, 8MB RAM, 40MB disk space,
CD-ROM version requires CD ROM.
Install Program: Uses the InstallShield Wizard.
Review: This program starts with a health interview and suggestions for
improving your lifestyle. There is also a videotape, which I haven't
seen yet. BalancePC provides a library of reference materials about
diabetes, at least in the CD-ROM version, and keeps very elaborate
records of diet, exercise, insulin, etc., with a very easy to use
interface. The program downloads readings from Accu-Chek, One Touch,
and Precision meters.
It allows the user to edit out any readings that should not be included.
Once input and edited, it transfers readings to a database; this transfer
is rather slow.
The graphs rely heavily on color, so are not transparently available
to show one's physician. The combined readings are fairly unreadable;
however, one can print each time of day out separately.
Another limitation is that it doesn't read a Profile very well--it
failed to read my insulin data from the Profile, or the event
codes; however, it did use time of day, which would work with the
Touch II.
Overall, the program has a lot to offer to assist in management of
diabetes; however, there are better programs for downloading
and displaying data from a meter. I have therefore put in a more extensive
review under "Other Software."
Part 3. Software for the Macintosh
1. BloodPlot 0.91beta
Cost: Freeware
BloodPlot is now at ftp://gila.la.asu.edu/diabetes/
Author:
Eric Jensen
1221 E. Johnson St. #1
Madison, WI 53703 USA
jen...@gila.la.asu.edu
Requirements: At least 1536K free memory. It has been verified that
it runs on a Centris with System 7.5, and it probably runs
on any Mac with enough free memory. The Disk footprint is just 400K.
Review: Like the much older Touch2 Program, this is freeware. The outputs
include an Excel text file and a histogram plot. For my purposes, this
is adequate, if not as attractive as the commercial program; on the other hand
it is the only program for the Macintosh, so it wins the Annual Award
for best Macintosh program to download glucose readings.
It is supposed to be Profile compatible, but I can't test that at this time.
===================================
2. SweetSheet
Author: Alaric Faulkner
Available at http://www.diabetesnet.com/software.html
Information from Michel Eytan (ey...@dpt-info.u-strasbg.fr)
Section B: Software for other meters.
1. Glucofacts(R)+ Diabetes Management System software
I have reproduced (without comment) a description of a software package for
the Glucometer M/M+. This description was emailed to me by Chris Trippel, who
works for the manufacturer. (I don't have a Glucometer.)
This software works with the Glucometer M and M+ meters.
Cost: $49.95.
Call: 1-800-348-8100.
The following is a description of the Glucofacts(R)+ Diabetes Management
System software.
Miles Inc., Diagnostics Division developed the Glucofacts(R)+ Diabetes
Management System to collect data from Glucometer(R) M and
Glucometer(R) M+ Blood Glucose Meters, store the data in files, and
integrate this data into a complete series of useful statistical
reports and graphs which can be evaluated on-screen or via hard copy.
Notes: Glucofacts+ DMS runs in the DOS environment.
The Glucofacts+ DMS version 2.01 ships on 3 1/2" disk only.
There is no demo software.
The price for the Glucofacts+ DMS version 2.01 is $49.95.
The product code is 5044B.
The Glucofacts+ DMS version 2.01 (5044B) can be ordered by
calling 1-800-348-8100. You will be asked to provide the serial
number on your Glucometer M+/M.
For more information on data management products such as Glucofacts+ DMS
please contact:
Miles Inc. - 1-800-348-8100
Thank you for your interest in Glucofacts+ DMS.
Chris Trippel
2. Level (referenced above). This program does One Touch, Glucometer, and
AccuChek meters, and does have a demo version. $79.00
For all meters, hardware must be ordered from the meter vendor; for the
Glucometer and AccuCheck, basic download software must be ordered as
well. This program then imports the downloaded data and does additional
analyses beyond that provided by the vendor-supplied software.
3. In Touch
Cost: $89.99, or $69.99 with purchase of One Touch Profile Meter
From Johnson and Johnson, U.S. 1-800-227-8862, Cananda, 1-800-663-5521.
4. Mellitus Manager (See above)
This program, according to the ad, reads AccuChekR Advantage and Easy, and the
Medisense Precision and Companion/Medisense 2 meters, but I have only
been able to test its operation with my Touch2 meter.
It was the easiest of the Touch2 programs to use, and is highly
rated for those with Touch2 meters, so it might be worth checking out
for those with other types of meters.
=============End of Part I=================
II. Other Software Programs (Nutritional Databases, etc.)
----------------------
Commercial Logbooks (these programs track your data like paper logbooks,
but do not download from a meter). All track test results, insulin, and meals.
Insulin Therapy Analysis
System: Windows
Cost $49.95 + $4 S&H
Call: 1-800-510-1024
Predicts impact on blood glucose of various events.
Blood Glucose Diary
Downloadable from Prodigy
-------------------------
SUGARMINDER 2.1
Cost: U.K. 39.95 pounds sterling.
System: Windows
Phone: +44 481 832 631
Fax +44 481 832 515
Contact:
Pulse Technology Group
36 Caro Mio 1, Sark
Channel Islands, GB (via Guernsey) GY9 0SE
10063...@compuserve.com
Free demo available on compuserve. Since I don't review demos,
no review is available at this time.
-------------------------
Comprehensive Programs
Balance PC
Cost: $59.95, available in phamacies
Contact: MediLife, Inc.,
30 Monument Square
Concord MA 01742
Toll Free: 1-888-656-5656
Features: Lifestyle interview and suggestions, food database, reports,
downloading of "leading" meters. Multimedia lessons on diabetes management.
Internet access package. Multiple-users database. Video on usage.
Requirements:Windows (3.1, 3.11, WFW) or Windows 95, 8MB RAM, 40MB disk space,
CD-ROM version requires CD ROM.
Install Program: Uses the InstallShield Wizard.
Review: This program appears in the downloading section; however, the
download feature is rather an afterthought. The program includes a video-
tape explaining that it enables the user to record lifestyle details
in less than 3 minutes a day. The video explains how to use the program,
which is easily the most sophiticated comprehensive program I have seen.
It has on the CD-ROM an extensive library of books to help the users
improve their lifestyles. It explains diabetes for the new user, and
has tips and information for experienced diabetics. It has provisions for
up to 8 users, so all members of the family can track their weight, diet,
medical check-ups, illnesses and exercise, which is not a bad idea even for
non-diabetics.
It provides a diabetic cookbook, and has a large database of foods and
nutritional analyses, so one can, for example drag a bowl of cereal from
the food window to the log window and have exchanges, vitamins, etc.
automagically added to the log.
As the video explains, the record-keeping is the main function of the
program, followed by the library. The ability to download from a
download capable meter is the last item mentioned, and is not as good
as some of the other programs; it does not yet support the Profile, for
example.
Overall, this can be a very worthwhile program for the person who is
sufficiently motivated to use information technology to improve their
control.
Food Databases
The MEALMATE.ZIP on ftp.demon.co.uk is a typical example of a shareware food
database. It has exchange equivalents for many common foods, and a recipe
function that adds ingredients to compute the exchange equivalent of the
recipe.
It is a simple, easy to use program, although a cracker was listed as a meat
exchange, so, like all shareware, it is to be used at the user's risk.
The author requests donations of whatever the user thinks the program is
worth.
A number of food databases are available from Nutrisoft for persons with heart
problem, obesity, etc. The one most relevant to this group is Diabetic
Nutrition. All these databases are available from Nutrisoft, P.O. Box 8226
Stanford, CA 94309. The cost is $39 per copy. The entire database includes
approximately 10,000 food items. Shareware versions may be obtained from
America Online, Compuserve, ftp.cica.indiana.edu in
/pub/pc/win3/misc/nsdn33.zip
(URL: ftp://ftp.cica.indiana.edu/pub/pc/win3/misc/nsdn33.zip)
This has been submitted to ftp.demon.co.uk as well. These programs, while
distributed as shareware, are commercial quality with a nice user interface
and
a large database of food items. They also have nutritional information based
on
current weight, activity level, etc. They can be reached by email at
Nutr...@aol.com
Ohio Distinctive Software Executive Diet Helper and Weight Loss Planner
Cost: $8.00 + $3.00 shipping and handling
Platform: PC or Macintosh
Review: I don't have the latest program. An earlier version was quite
simple, but not bad for the price.
Available from:
Ohio Distinctive Software
4588 Kenny Road
Columbus, OH 43220
(614) 459-0453
C. Educational/Simulation Software
AIDA
Cost: freeware
Contact: http://www.diabetic.org.uk/aida.htm
Requirements: DOS with 540K free RAM
Review:
This program simulates the glycemic effects of carbohydrates and insulin. It
is
intended to be a training tool, both for the individual diabetic and for
the student of diabetes. The student is given cases where the patient is
out of control, and asked to prescribe a new regime to achieve euglycemia.
Answers are provided.
The individual diabetic can enter carbohydrates ingested and insulin taken,
and
compare this with actual blood sugar readings to understand, in general,
what is happening. The program warns that it's recommendations should NOT
be used by the individual for modifying their regime; the only function
of the recommendations is for the training described above.
The program is a DOS program with a user interface that is not altogether
adherant to modern interface design principles; however, the program
is a useful tool for the student and/or diabetic.
I highly recommend it for medical students, interns, and residents. For
diabetic educators who want to use it in their training, it may well
be a useful adjunct. Some diabetics may also want to experiment with the
program for a better understanding of their disease, again, with the caveat
that its recommendations are not intended to be used in lieu of a
diabetologist.
D. Unclassified Software
1. GlucoStat V2.0
Cost: $65
Contact:
Gary P. Argento
Glucoware Company
P.O Box 43369
Cleveland, Ohio 44143-0369
PH: 800-774-4448
Review: Not available at this time. Mr Argento asked that his product
be included, but I really don't know anything about it yet. As soon as
I get more information, I'll include it. Meanwhile, interested persons
can call his 800 number.
NEWTON SOFTWARE
Pocket DiabetiCare 1.10
Cost: $20
Available from: http://www.halcyon.com/dcapp/OrcaWare
Review: Not available. However, for those seeking Newton Software, this is
the first product I've seen.
PSION PDA SOFTWARE
new Diabetes Management software by Klaus Stahl for the Psion Series 5/mx (a
PDA).
Its called "DiabetesManager" version 2.00 (ENGLISH and German) and replaces
the former ZuckTage/ZuckTag5/SugarDay. The shareware is about $ 35 for
registration.
E-mail: Klaus...@talknet.de
Internet: http://www.talknet.de/~klausstahl/DiabetesManager.htm
Mailing list: http://www.onelist.com/subscribe/DiabetesManager
================End of Part II=====================
Part III. Other Electronic Information Resources
FTP Site
Ian Preece has also set up an anonymous ftp site just for diabetes related
programs at ftp.demon.co.uk
He has an article about this site and how to use it in this newsgrous.
Readers with ftp or a good mail program can get software from this
site; as of March 1995, several programs were available. I found the
following:
Diabetic Assistant (1 and 2), bsm, glucofacts +, mealmate, nsdn version 3.3
otview, and touch2. OTVIEW, TOUCH2, and Diabetic Assistant are reviewed
above. I believe the others are either logbooks or nutrition/meal planning
programs. I expect many other shareware and
freeware programs will be posted here eventually. A brief
discussion of ftp and ftpmail is available above in the section on getting the
Touch2 program by Vic Abell. Either ftp or ftpmail may be used to access any
of
these programs.
Web Sites
A good site is at
http://www.niddk.nih.gov
the National Institute of Diabetes and Digestive and Kidney Disease
of the National Institute of Health. Unless and until it gets Newted, this
would
seem to be the Official Government Diabetes Site. A great deal of information
for diabetics, researchers (and, of course, diabetic researchers).
The official American Diabetes Associate site is at (where else)
http://www.diabetes.org
It looks like a ported gopher site, complete with cruft.
A good place for a newly diagnosed diabetic.
One of the better UK sites is at
http://www.diabetic.org.uk
This site provides AIDA, among its many other offerings.
A top rated site qua site is
http://www.nd.edu/~hhowisen/diabetes.html
This was rated in the top 5% of all Web pages. Well laid out, with
lots of neat Web tricks, and some useful diabetes information and links.
A small private Diabetes Site is at
http://www.airnet.net/~jsmith/Diabetes.html
There's not much here, yet, but I understand it's under development.
I mention it because it links to this faq.
Diabetes Net is at
http://www.diabetesnet.com
"For Active and Proactive People with Diabetes"
This is primarily a commercial site to sell diabetes products, but
it has quite a bit of useful information.
For more information on Biostore, check out their
website: http://www.bizscape.com/biostore
This site has some general information, plus a much more extensive
description of biostore products than is given here.
http://pages.prodigy.com/CA/nutrigenie/rxdmdiet.html
has some free nutritional software
The following was one of the first diabetes sites on the Web.
It was a good site, but was down as of 18 October 1995 at 5pm EDT.
The disclaimer said it is down indefinitely due to circumstances
beyond the authors' control.
"Great news, the Diabetes Knowledgebase has now officially moved to its
new permanent home at:
http://www.biostat.wisc.edu/diaknow/index.htm
Also, since it is now an officially sanctioned site, it will
have a great deal of permanence." --official announcement of move.
As of 5pm EDT on 18 October, this site was down (:-(
Also, some diabetic information may be found at
http://cancer.med.upenn.edu:3000/
"World Health Net has been launched! Its current address is
http://oceania.org/world_health/
" -- official announcement of opening.
Pharamceutally sponsored sites
http://www.ihlth.com - OTC products for diabetics
http://www.epill.com - Rx and OTC products
Commercial Services
Software, discussion and support groups, and general information on diabetes
are available from America Online, Compuserve, and Prodigy.
America Online
This service provides a large diabetes section. I found about 20 programs to
help with various aspects of diabetes management.
Compuserve. (out of date)
When I last checked two years ago, Compuserve had a large library of
shareware programs for diabetes, and a highly recommended diabetes forum. I'm
afraid I need to revisit Compuserv, as all I wrote earlier is now out of date.
Español
Ya tenemos un mailinglist en español. Si quieres, escribe Vd. a
glucosa...@filnet.es o a re...@filnet.es para subscribir.
Websites en Español:
http://members.xoom.com/adezaragoza
http://www.pagina.de/adezaragoza
Edward Reid
Posting-Frequency: biweekly
Last-modified: 22 June 2002
Changes: see part 1 of the FAQ for a list of changes to all parts.
------------------------------
Subject: READ THIS FIRST
------------------------------
Subject: Table of Contents
------------------------------
Subject: What is the DCCT? What are the results?
The Diabetes Control and Complications Trial was a large multi-center
trial involving over 1400 volunteer patients with type 1 diabetes. It
began in 1983, ramped up to full speed by 1989, and ended early in 1993
when the investigators felt the results were clear. The volunteers were
all undergoing "standard" treatment when they were recruited, meaning
one or two injections per day. They were randomly assigned to two
groups. One group continued as before. The other group received
intensive treatment aimed at achieving blood glucose (bG) profiles as
close as possible to normal. The intensive treatment involved multiple
bG checks per day, multiple injections and/or an insulin pump, and
access to and regular consultation with a team of treatment experts.
It is particularly important to note that intensive treatment was
defined as a collaborative effort involving the patient and a skilled
team of health care professionals. It was not defined by particular
techniques, although certain techniques were typically used. The
frequent consultations and availability of a professional team were
critical components of intensive therapy.
The results show that the intensive treatment group did indeed achieve
bG levels closer to normal, and that they experienced far fewer
diabetic complications though also more hypoglycemia. In particular,
patients who maintained HbA1c levels around 7% appear to be much better
off than those whose HbA1c hovers around 9%. (See caveats in the
section on HbA1c.) Though it is not possible to separate the effects of
all the aspects of the intensive treatment, it is reasonable to believe
that lowering average bG may be effective even in isolation from the
other aspects of the intensive treatment. In its position statement,
the ADA says
Patients should aim for the best level of glucose control they can
achieve without placing themselves at undue risk for hypoglycemia or
other hazards associated with tight control.
Though type 2 patients were not included in the study, it is generally
believed that the results showing the benefits of tight control apply
to type 2 patients as well.
The entire position statement was published in most of the ADA's
publications (see "could you recommend some good reading") in the
summer and fall of 1993.
The formal report detailing the results was published in The New England
Journal of Medicine, aka NEJM, of September 30,1993 (v 329 pp 977-986).
The following discussion is based on that article.
Several DCCT subjects participate in m.h.d and are willing to answer
questions related to the personal aspects of DCCT participation.
------------------------------
Subject: More details about the DCCT
The study placed subjects into two cohorts, primary prevention or
secondary intervention, depending on duration of diabetes and existing
complications -- the primary prevention cohort were those with
essentially no complications.
Specifically: all subjects met these criteria:
Insulin dependent as evidenced by deficient C-peptide secretion
Age 13 to 39 years at entry to the study
No hypertension, hypercholesterolemia, severe diabetic complications,
or other severe medical conditions
Meet the criteria for one of the cohorts
and were separated into the two cohorts by these criteria:
Primary Secondary
Prevention Intervention
Cohort Cohort
Duration of IDDM 1-5 yrs 1-15 yrs
Retinopathy none detectable very mild to moderate
nonproliferative
Urinary albumin < 40 mg / 24 hr < 200 mg / 24 hr
Within each cohort, the subjects were randomly assigned to either
conventional therapy or intensive therapy. Thus the study compared
intensive to conventional therapy in two different cohorts. The two
questions the study was mainly designed to answer were
1) Will intensive therapy prevent the development of diabetic
retinopathy in patients with no retinopathy (primary
prevention), and
2) Will intensive therapy affect the progression of early
retinopathy (secondary intervention)?
Conventional therapy included one or two injections per day, daily self
monitoring of blood or urine glucose, education, quarterly
consultations, and intensive therapy during pregnancy. Intensive
therapy included three or more daily injections or an insulin pump, bG
monitoring at least 4x/day, adjustment of insulin dosage for bG level
and food and exercise, monthly personal consultations and more frequent
phone consultations.
To simplify a lot, the DCCT showed the following changes in the
intensive therapy groups compared to the conventional therapy groups.
Note that '-' shows a decrease, '+' shows an increase, in the number of
patients affected. Patients were judged as affected or not based on
binary criteria, so the results only say how many subjects were
affected, not how severely those subjects were affected.
Intensive therapy compared to conventional therapy:
Primary Secondary
Complication Prevention Combined Intervention
------------ ---------- -------- ------------
Retinopathy(*) - 75% - 55%
Nephropathy(*) - 35% - 45%
Neuropathy(*) - 70% - 55%
Hypoglycemia(*) +200%
Weight gain(*) + 33%
Hypercholesterolemia(*) - 35%
(*) This brief table begs many questions about what exactly was
measured and how. For more details, read the paper.
There were no detectable differences on several measures:
Macrovascular disease
Mortality
Changes in neuropsychological function
(a feared result of severe hypoglycemia)
Quality of life (based on a questionnaire)
Some limitations of the study: type 1 only, patients young and with
short duration (under 15 years) of diabetes, and short duration of the
study (5-9 years). Measured only number of subjects affected according
to binary criteria, not by measurement of severity of complications.
Excluded patients who already had severe complications and who thus
might benefit the most. The difference between the groups increased
during the study, but there is no proof that the difference would
continue to increase with time.
It is tempting to extrapolate the results to all diabetic patients --
all types, ages, and durations -- and there is at least some support
for doing so. However, the DCCT by itself does not show results for
type 2 patients, older patients, patients who have had diabetes for
many years, or those who already have severe complications. On the
other hand, a different group of subjects might shows differences in
areas such as mortality and macrovascular disease, where the young DCCT
cohorts simply did not have significantly measurable incidence. The
DCCT subjects are being tracked in a followup study which may shed
light on some of the unanswered questions.
Secondary analysis of the data indicates that retinopathy decreases with
decreasing HbA1c. This measure was not part of the study design and is
more difficult to interpret, but still shows clearly a correlation
between HbA1c and retinopathy.
------------------------------
Subject: DCCT philosophy: what did it really show?
It is often stated that the DCCT proved that tight control or lowered
HbA1c reduces complications. This is not the case. The controlled
variable in the DCCT was intensive vs conventional therapy, and
intensive therapy was defined by several factors including a team of
skilled health care professionals acting in partnership with the
patient. The results show that intensive therapy results in both
lowered HbA1c and fewer complications, but do not show that one causes
the other. The lead authors provide a good summary of this point in a
followup (NEJM 330:642, March 3, 1994):
We want to stress that the most valid interpretation of the trial
is that intensive therapy, with the **goal** of achieving blood
glucose concentrations as close to the nondiabetic range as
possible, delays the onset and slows the progression of long-term
diabetic complications. The secondary analyses support the notion
that lower glycosylated hemoglobin values are associated with a
lower risk of progression of retinopathy, but they do not prove
that hyperglycemia in itself causes retinopathy. [emphasis added]
Many of us believe, and believed before the DCCT, that actually
achieving good control aids our health. The DCCT adds weight to this
case but does not prove the point.
Edward Reid
Posting-Frequency: biweekly
Last-modified: 22 June 2002
Changes: see part 1 of the FAQ for a list of changes to all parts.
------------------------------
Subject: READ THIS FIRST
------------------------------
Subject: Table of Contents
------------------------------
Subject: Online resources: diabetes-related newsgroups
On the Usenet, the misc.health.diabetes newsgroup carries most of the
messages related to diabetes. Volume runs about 200-250 articles/day. Suppose
you obtained this FAQ by some method other than by reading m.h.d and you want
to participate. If you already have access to Usenet news, just subscribe to
misc.health.diabetes; the exact method depends on the software used at your
site, so you should inquire locally for details. If you do not have access to
Usenet news, inquire locally about obtaining such access. The key words are
"I want to participate in the Usenet newsgroup misc.health.diabetes". Usenet
is available at most colleges and universities, many companies, all of the
large commercial services (including Delphi, Netcom, America Online,
Compuserve, Prodigy), many smaller local services, most Freenet systems,
and many locally run BBSs. Some of these have selective news feeds, and you
will have to ask them to get misc.health.diabetes before you can subscribe
via their system.
m.h.d is not gatewayed to any mailing list, and to my knowledge is not
archived anywhere as such. However, DejaNews has all of Usenet from March
1995 to present online and available to the public, and plans to extend the
scope farther into the past. You can create a filter specifying only the
newsgroup you want, and then search for key words. See
Another newsgroup, alt.support.diabetes.kids, has a much smaller volume of
articles, about 2-3 per day. Being in the alt.* hierarchy of newsgroups, its
propagation is somewhat restricted compared to misc.health.diabetes. To
obtain access, follow the same instructions as for m.h.d, above.
Other Usenet newsgroups which might be relevant are
rec.food and its subgroups
the sci.med hierarchy
the alt.support hierarchy, especially alt.support.diet
bit.listserv.transplant (only available at sites that carry bit.* --
see the description below of the TRNSPLNT list)
------------------------------
Subject: Online resources: diabetes-related mailing lists
Several public electronic mailing lists have diabetes-related content. The
main alternative to a newsgroup is the DIABETIC list, which carries about
60-80 messages/day. Its charter is to be "a support and information group for
diabetics". The overall flavor and atmosphere are different from the m.h.d
newsgroup, so if you find that you are uncomfortable with one, try the other.
If you subscribe to the DIABETIC list, be prepared for the large volume of
messages. If you have not dealt with this volume of email before, it will be
quite disconcerting to see so many messages appear in your personal mailbox,
and I advise that you consider one of the following methods to avoid being
overwhelmed:
-- set up a mailbox (aka userid, account, screen name) separate from
your normal personal mailbox in which to receive the mailing list.
You will have to ask locally whether this is possible on your system.
You may also be able to use your mail program to filter mailing list
messages into a separate mailbox.
-- convert to the digest as soon as you have subscribed. The digest
option collects messages into large postings called digests (a misuse
of the word, as all messages are included in their entirety). This
digest is sent daily, or when its size passes a limit (currently 2000
lines). Convert to digest form by sending a message addressed to the
listserv (see below) with a message body containing
set diabetic mail digest
TYPE_ONE is a low to moderate volume mailing list for discussion of type 1
diabetes, intended primarily as a support group. It carries about 10
messages/day. There is no digest option. If you get any error messages from
"majordomo", be sure to write directly to the list owner,
jamyers(AT)netcom.com, as sometimes the software at netcom prevents him from
replying directly.
DIABETES-EHLB started as an Electronic HighLights Bulletin to distribute
information presented at the ADA conference in June 1996. It was carried
forward as a moderated mailing list. The moderator plans to try to keep
discussions focussed on specific topics.
TRNSPLNT is a low volume mailing list for discussion of organ transplants. It
carries about 10 messages/day. It is relevant to diabetes because
complications of diabetes often lead to kidney transplants. TRNSPLNT is
gatewayed with the newsgroup bit.listserv.transplant, which is available at
Usenet sites which carry the bit.* hierarchy of newsgroups.
DIABETES-NEWS is a one-way list provided by _Diabetes Interview_ magazine. It
provides a sample, one article per week, from the printed magazine. See the
section on "Could you recommend some good magazines?" for more information
about the printed magazine.
AUTOIMMUNE is a moderated, low volume list carrying technical information
about research on autoimmune disorders, including type 1 diabetes.
HYPO is a moderate volume mailing list for support and information on
hypoglycemia (as a medical condition as opposed to an insulin reaction).
To subscribe to the mailing list in the first column, send a message to the
email address in the second column (or to the alternate if given) containing
the command in the third column. Note that Firstname Lastname is your real
name, such as John Doe. The listserv software will use the email address in
your message header for your subscription. If you have trouble sending email
to the listserv, or if you receive no response, then you will need the help
of someone at your site.
DIABETIC listserv(AT)lehigh.edu subscribe diabetic Firstname Lastname
TYPE_ONE listserv(AT)netcom.com subscribe type_one
DIABETES-EHLB
listserv(AT)shrsys.hslc.org subscribe diabetes-ehlb Fstnm Lstnm
TRNSPLNT listserv(AT)wuvmd.bitnet subscribe trnsplnt Firstname Lastname
listserv(AT)wuvmd.wustl.edu
DIABETES-NEWS
diabetes-news-request(AT)lists.best.com subscribe
AUTOIMMUNE maiser(AT)ksg1.harvard.edu Subscribe autoimmune_research
HYPO hypo-request(AT)iceblue.com.au subscribe hypo
NECROBIOSIS necrobiosi...@yahoogroups.com [no command needed]
web page: http://groups.yahoo.com/group/necrobiosis
For up to date information and more diabetes-related mailing lists, see
Rick Mendosa's Online Diabetes Resources FAQ at
http://www.mendosa.com/faq.htm
------------------------------
Subject: Online resources: commercial services
Most of the information here comes from David Cohler <ar051(AT)lafn.org>, who
tried out all the online services and sent me his reviews. Thanks, David! I
don't have any information about commercial services in countries other than
the US.
CompuServe has a very active "Diabetes Forum." In many respects, it is the
single most comprehensive online resource for diabetics, featuring active
participation from several dozen countries, an extensive document library,
and an extensive software library. The moderators ("sysops") are quick to
pounce on misinformation and either correct it or delete it. No flaming
allowed. As of late 1995 the main drawback to CIS is price; even under a new
pricing policy, accessing the Diabetes Forum just 20 minutes a day could
result in charges of US$30 per month.
America Online has a diabetes support area. It is newer and smaller than
Compuserve's, but growing. The health forum has a number of information files
on diabetes which users can read and download. These files generally contain
good advice and some explanation, but not in-depth explanation.
Also on AOL, each Sunday evening at 8:30 Eastern Time (US) a diabetes support
group meets in a "private room" named "Diabetes". For more information, email
Jim Lewis <jblewis(AT)aol.com>.
Prodigy has a relatively small but active and very friendly support group
accessed by "jumping" to "Medical Support BB" and then selecting "diabetes"
as the bookmark configuration. The board is monitored by several CDEs.
Although there is some discussion of scientific research, etc., the
preponderance of posts concerns support for people having trouble with
self-management. This is an excellent place for newly-diagnosed diabetics who
still need a lot of basic information and emotional support. Moderated (no
flaming allowed).
Delphi has an active diabetes support forum, accessed by typing GO REL DIA.
Lisa Crawford <LISA_POOH(AT)delphi.com> is the host and forum manager.
Genie has a miniscule diabetes support area, configured as an RT ("Round
Table," Genie's term for BB). As of May 1995, traffic was at the rate of a
dozen posts per week.
------------------------------
Subject: Online resources: FTP
Demon Internet Services, a UK service provider, donated FTP space for
diabetes-related materials due to the urging and coordination of Ian
Preece <ianp(AT)darktower.com>. This cooperative endeavor was launched
with an empty directory in June 1994.
FTP has taken a back seat to the WWW. However, this site is one of the
very few soliciting donations as a cooperative endeavour.
Using the World Wide Web will be the easiest access to ftp for most new
users:
ftp://ftp.demon.co.uk/pub/diabetes/
You can also use a traditional FTP program.
To submit material, upload it to the "incoming" directory. After making
a submission, send email to Ian Preece <ianp(AT)darktower.com> telling him
about the file you have submitted.
------------------------------
Subject: Online resources: World Wide Web
I list a few excellent starting points for diabetes information on the
web. The maintainers of these pages are putting a lot of effort into
providing good information and links to other sites, and I'm not going
to try to duplicate their work here.
One of the best starting points is Jeff Hitchcock's Children with
Diabetes. Don't judge Children with Diabetes by the title alone; it has
extensive links to diabetes information of all sorts and is by far the
most extensive compilation on diabetes that I've seen on the net.
http://www.childrenwithdiabetes.com/
Rick Mendosa <mendosa(AT)cruzio.com> maintains a very extensive list of
online resources for diabetes, including many informational and
commercial web sites, and a list of BBSs. It is very likely the most
complete list available, and because it's simply a list, it is much
easier to read than sites with lots of complex internal links. Rick
also keeps one of the most thorough available lists of glycemic index
values for foods.
Another excellent compilation of links to diabetes-related web sites is
the Diabetes Monitor of the Midwest Diabetes Care Center. It's
maintained by William Quick and is exceptionally easy to navigate.
http://www.diabetesmonitor.com
Yahoo has links on a huge variety of subjects, so if you want more than
just diabetes information you can shorten this URL:
http://www.yahoo.com/Health/Diseases_and_Conditions/Diabetes
Ian Preece <ianp(AT)darktower.com> is maintaining a web site in
conjunction with the Demon FTP site described above:
http://www.demon.co.uk/diabetic/
You can reach a WWW-formatted version of this FAQ via the URL
http://www.faqs.org/faqs/diabetes/
or you can get the plain text by FTP from
ftp://rtfm.mit.edu/pub/usenet/news.answers/diabetes/
The American Diabetes Association (ADA) has put its entire set of
Clinical Practice Recommendations online in full. Go to the ADA
home page at
and follow the link to "Clinical Practice Recommendations", which
when I last checked was down the left edge under the heading "For
Professionals".
Since these are oriented toward health care professionals, they provide
a wealth of detailed recommendations for actual health care practice.
Donald Lehn <dal...@facstaff.wisc.edu> was probably the first to put a
server with diabetes information on the web. Lehn's Diabetes
Knowledgebase has been offline since August 1995, and is apparently
gone for good.
------------------------------
Subject: Online resources: other
Most online resources previously available via other means are now
available via the web. Since these are thoroughly cataloged by the best
of the diabetes web sites (see previous section on "Online resource:
World Wide Web), I've dropped this coverage from the FAQ.
------------------------------
Subject: Where can I mail order XYZ?
XYZ is most often blood glucose measurement strips, especially for those who
don't live near discount pharmacies. Mail order prices are not always lower
than local prices. Remember that there is an advantage to going to a single
pharmacist for all your drugs, if that pharmacist is knowledgeable about
interactions and tracks all the drugs you use. Adjustments will be slower if
you mail order. Never mail order unless you are certain about what you need.
That said, here's a list of mail order firms specializing in diabetes
supplies (and one for the blind). Aside from those listed below, I've not
heard of any outside the US, perhaps because the health care systems
elsewhere don't encourage the practice. Most of these advertise in _Diabetes
Forecast_ (see section on journals). This list is presented with no
recommendations, pro or con. Each issue of _Diabetes Forecast_ also contains
a column summarizing recommendations for ordering health supplies by mail.
Most will send a catalog or price list on request.
Many of these now have an online presence on the WWW. Jeff Hitchcock's
Children with Diabetes (see "Online resources: World Wide Web") has links to
quite a list on suppliers with information online.
* A R Medical Supplies 1-800-525-8362
*@American Medical Supplies 1-800-434-3536
Chronimed Pharmacy 1-800-876-6540
or +1 612 546 1146
Diabetes Supplies 1-800-622-5587
* Diabetic Care Center 1-800-633-7167
@Diabetic Depot 1-800-537-0404
Diabetic Emporium 1-800-231-6827 sugar-free foods
Diabetic Express 1-800-338-4656
Diabetic Promotions 1-800-433-1477
or +1 216 943 6185
* Edwards Healthcare Svcs 1-800-793-1995
GEM Diabetes Supplies 1-800-793-1995
H-S Medical Supplies 1-800-344-7633
Hospital Center Pharmacy 1-800-824-2401 part of the Joslin Diabetes Ctr
ask for bg meter comparison chart
* Liberty Medical Supply 1-800-762-8026
* National Diabetic Pharmacies 1-800-467-8546
or +1 703 389 0201
* Patient Care Svcs 1-800-882-5238
* Preferred Rx 1-800-843-7038
SugarBusters Diabetes Ctrs 1-800-867-8020 http://www.iquest.net/sugarbusters
/sugarbusters.html
* Suncoast Pharmacy 1-800-799-1991
*@Thriftee Home Diabetes Care 1-800-847-4383
* = specializes in insurance or Medicare billing
@ = advertises "Hablamos Espanol"
in Canada:
Diabetes Specialty Shop 1-800-465-3336 (Canada)
In Australia:
Diabetics Australia 149 Pitt St Redfern NSW 2016
On a slightly different note, Associated Services for the Blind (919 Walnut
Street, Philadelphia PA 19107, +1 215 627 0600, fax +1 215 922 0692) runs a
nonprofit store specializing in supplies for the blind. See their home page
at
http://www.libertynet.org/~asbinfo
or email them at asbinfo(AT)libertynet.org.
------------------------------
Subject: How can I contact the American Diabetes Association (ADA) ?
The ADA has local offices in many cities. Check your local phone book first.
To contact the national organization, call 1-800-232-3472 or +1 703 549 1500.
This will reach all departments. Or write
American Diabetes Association
1660 Duke Street
Alexandria, VA 22314
USA
The ADA offers aid to diabetic patients, books, and journals ranging from
general to research. All can be ordered by phone. They maintain lists of
physicians with special interest and/or training in diabetes. New patients
and their families needing advice are encouraged to call. They may be able to
help in dealing with bureaucratic problems.
The ADA is on the web at http://www.diabetes.org. The web site has a great
deal of useful information, but unfortunately it is very badly organized (as
of June 1996). It includes lists of ADA publications and ordering
information. One section that is particularly useful is the ADA's Clinical
Practice Recommendations, which are all online in full. Go to the ADA
home page at
and follow the link to "Clinical Practice Recommendations", which
when I last checked was down the left edge under the heading "For
Professionals".
------------------------------
Subject: How can I contact the Juvenile Diabetes Foundation (JDF) ?
Check your phone book for a local office, or call 1-800-533-2873.
The JDF also has a web site at http://www.jdfcure.com/.
The JDF's motto is "finding a cure for diabetes", though apparently they only
mean for type 1 diabetes. They are rather obnoxious in their rejection of the
value of support and treatment other than a total cure. Despite this position,
the JDF in fact does a great deal of support work.
------------------------------
Subject: How can I contact the British Diabetic Association (BDA) ?
The British Diabetic Association
10 Queen Anne Street
London W1M 0BD
Telephone 0171 323 1531 (+44 171 323 1531)
CARELINE 0171 636 6112 for information about diabetes
The BDA produces a bi-monthly magazine for members called "Balance".
Membership is UKP 12 a year.
------------------------------
Subject: How can I contact the Canadian Diabetes Association (CDA) ?
The CDA has local offices in many cities. Check your local phone book first.
To contact the national organization, call +1 416 363 3373, or write
Canadian Diabetes Association
15 Toronto St, Suite 800
Toronto, Ontario M5C 2E3
Canada
In Canada, call 1-800-847-SCAN.
The CDA is on the web at http://www.diabetes.ca.
The B.C. - Yukon Division of the CDA maintains an information center on the
Vancouver Freenet. It includes contact information for regional divisions of
the CDA. See the section "Online resources: other".
------------------------------
Subject: What about diabetes organizations outside North America?
I can't list them unless someone sends me the information.
Ian Preece <ianp(AT)darktower.com> has started a list, which now has
contact info for several European organizations, at
http://www.demon.co.uk/diabetic/orgs.html
------------------------------
Subject: How can I contact the United Network for Organ Sharing (UNOS)?
UNOS (United Network of Organ Sharing) has a variety of information
concerning organ transplants and transplant centers. Contact UNOS at
(800)24-DONOR or +1 804 330 8602, or PO Box 13770, Richmond VA 23225, USA.
UNOS has a WWW page at
Email contact is Joel Newman <newmanjd(AT)comm5.unos.org>.
------------------------------
Subject: Could you recommend some good reading?
You mean to curl up with on the sofa? Oh, diabetes ... OK.
My favorite book is Mayer Davidson's _Diabetes Mellitus: Diagnosis and
Treatment_, published by Churchill Livingstone. Though written as a
medical text, anyone willing to plow through an occasional dense
passage and keep a dictionary handy will have no trouble with it. (See
below about medical terminology.) Being written mostly by a single
person, it is much better focussed than the "committee" books which are
so common. And it's very cheap for medical books, US$42 in 1994.
Charles Coughran <csc(AT)coast.ucsd.edu> recommends _Management of
Diabetes Mellitus Perspectives of Care Across the Lifespan_, Debra
Haire-Joshu (editor), Mosby Year Book, 1992, ISBN 0-8016-2429-0. He
says it's as good as Davidson, readable, and aimed at a similar audience.
Coughran and Steve Kirchoefer <swkirch(AT)chrisco.nrl.navy.mil> recommend
_Joslin's Diabetes Manual_ by Krall and Beaser, Lea&Febiger 1988.
Though somewhat lacking in consistency due to the multitude of writers,
it's a useful practical book. The Joslin Institute is world renowned
for its support of diabetes research and treatment, and the price of
the book is reasonable.
Coughran further recommends _Joslin's Diabetes Mellitus_ (13th edition)
edited by Kahn and Weir, 1994. It's another book that suffers a lack of
consistency due to the multitude of writers, but it contains a wealth
of information. Lots of biochemistry and also sections on practical
day-to-day management. Oriented toward health care professionals. 1068
pages, $125.
Terence Griffin <griffin(AT)cam.nist.gov> recommends _Therapy for
Diabetes Mellitus and Related Disorders_. It's a professional level book
compiled and published by the ADA, now in its second edition. See below
for ADA ordering information.
Steve Marschman <sc_marschman(AT)pnl.gov> recommends John Davidson's
_Clinical Diabetes Mellitus, A Problem-Oriented Approach_ (2nd
edition), published by Thieme Medical Publications, New York. Written
from a care-giver's perspective, it is an excellent technical resource
book with medical descriptions of diabetes mellitus, diagnosis,
treatment, complications, and concomitant problems. Price about US$150,
but often available used for much less. (As far as I know, the two
Davidsons, Mayer and John, are not related.)
The American Diabetes Association publishes a number of books with
basic diabetes information of various sorts -- self care, diet,
recipes, etc. Deb Martinson <llama(AT)drizzle.com> especially recommends
_The ADA Complete Guide to Diabetes_, about $6 in paperback and
published in 1996. See the ADA's web site at
or use the phone numbers or address in the following section.
Any university library will have a large number of books on diabetes,
and they will be grouped together on the shelves. Go and browse. The
books mentioned above can be found in most university libraries.
The rest of what I have to talk about is periodicals. See the next
topic.
------------------------------
Subject: Could you recommend some good magazines?
_Diabetes Interview_ is a popular monthly tabloid with a variety of
news stories, interviews, and lots and lots of advertising. It's run by
a journalist, Scott King, and it shows. Authority, to this publication,
always lies in people they talk to. They don't appear to read
scientific or medical literature as the basis or support for stories.
They do publish research summaries, but these are at the newswire level
with no apparent critical reading. No critical commentary accompanies
interviews.
Publisher Scott King has pursued some valuable projects, such as
organizing letter-writing to Ann Landers after she tried to shove
dining-out diabetics into the closet -- Landers published King's own
excellent letter. He has certainly advanced the cause of open
discussion of diabetes in general. But _Diabetes Interview_ has been
sidetracked needlessly at times, such as by allocating seriously
inordinate abounts of space and attention to minor issues such as the
animal/human insulin debate. They also regularly run a paid
advertisement for an herbal product which claims to "restore pancreatic
function" -- probably an illegal claim in the US.
_Diabetes Interview_ offers a sample (one article per week) as an
electronic mailing list and many articles on their web site. See the
section on "Online resources: diabetes-related mailing lists" for
information on the mailing list.
_Diabetes Interview_ subscription information: one year, US$20 in the
US, US$31 in CA and MX, $46 in other countries. Cancel after the first
issue if you don't like it
Diabetes Interview
3715 Balboa Street
San Francisco, CA 94121
http://www.diabetesworld.com
phone: +1 415 387 4002
US 800-234-1218
_Diabetes Self-Management_ is a bimonthly magazine containing generally
detailed articles oriented to helping patients with techniques and
skills -- diet, exercise, treatment, outlook, etc. They go into areas
not often covered, such as a recent series by Ann Williams on
low-vision tools and coping skills. The writers tend to have in-depth
knowledge of their fields and the information is well balanced. The
magazine emphasizes practical skills over basic knowledge, and spreads
itself a bit thin by trying to address itself to all diabetics. Those
who dislike Diabetes Forecast will find similar coverage in Diabetes
Self-Management but with more depth and aimed at a better educated
audience.
The _Diabetes Self-Management_ web site has full text of numerous
articles from back issues, about two articles from each issue.
_Diabetes Self-Management_ costs US$14/yr, or US$36/yr outside the US
and CA. To order, mail payment, call, or look on their website. They'll
send a free trial issue if you wish.
Diabetes Self-Management
P. O. Box 52890
Boulder, CO 80322
http://www.diabetes-self-mgmt.com/
US phone: 800-234-0923
Everything else I have to recommend comes from the ADA (see section on
ADA).
Here's what the ADA says about its own publications:
_Diabetes_ -- the world's most-cited journal of basic diabetes
research brings you the latest findings from the world's top
scientists.
_Diabetes Care_ -- the premier journal of clinical diabetes research
and treatment. _Diabetes Care_ keeps you current with original
research reports, commentaries, and reviews.
_Diabetes Reviews_ (in memoriam) -- the comprehensive but concise
review articles in ADA's newest journal are a convenient way for
the busy clinician to keep up-to-date on what's truly new in
research. Sadly, Diabetes Reviews ceased publication at the end
of 1999, a victim of the fact that medical libraries face a
crisis of rising subscription costs but flat budgets. The seven
volumes which were published are still an invaluable resource.
_Diabetes Spectrum_ -- translates research into practice for nurses,
dietitians, and other health-care professionals involved in patient
education and counseling.
_Clinical Diabetes_ -- For the primary-care physician as well as
other health-care professionals, this newsletter offers articles
and abstracts highlighting recent advances in diabetes treatment.
_Diabetes Forecast_ -- ADA's magazine for patients and their
families features advice on diet, exercise, and other lifestyle
changes, plus the latest developments in new technology and
research. It is a valuable tool for patient education.
Now for my own opinions.
_Diabetes Forecast_ is the mass market magazine, intended to be readable
by all literate diabetics. For US$24/year you can hardly go wrong. The
biggest problem with DF is that in the attempt to reach almost
everyone, it aims at a very low reading level -- perhaps eighth grade,
I'm not sure. This makes it tonally annoying and dilutes the
information content. Still, it contains useful information and is
excellent at promoting self-care and a positive self-image for persons
with diabetes.
_Diabetes Forecast_ is also one of the best places to look for
advertisements for diabetes-related products.
The remaining journals are of interest if you want to follow what is new
and under investigation in medical practice and research. The journals
vary in difficulty of reading. Though some knowledge of statistics and
chemistry helps, a general acquaintance with scientific method is
perhaps more important, and a smattering of familiarity with medical
terminology helps most. Luckily, medical terminology is basically
simple -- it mostly consists of putting together roots and affixes to
make specific terms. Learn a few dozen roots and you can make out most
of it. Try to have a dictionary at hand at first.
_Diabetes Care_ publishes papers on clinical research. I find many of
the papers to be interesting and applicable to my own management. With
the demise of _Diabetes Reviews_, DC plans to publish more review
articles as well.
_Diabetes_ is the ADA's journal primarily for basic research. Some of
the articles are interesting, but they run much more toward
biochemistry and mechanisms of metabolism. As important as basic
research is, few of the reports say little of value directly to
patients.
_Diabetes Spectrum_ is oriented toward health care practitioners.
It consists of reprints of important articles (sometimes several on
a topic) and summaries of related articles, plus original
commentaries from other authors. As such, it provides a broad
overview of topics for readers who don't have time to track down
lots of separate original articles. If you only have time to read
one technical publication, _Diabetes Spectrum_ is perhaps the best
choice -- the only competitor for this place is _Clinical Diabetes_.
_Clinical Diabetes_ contains focussed articles written specifically
for health care practitioners. It's very readable and to to the
point, another good choice for those wanting higher level reading
but not research articles.
The ADA has price structures for regular members and professional
members. A basic regular membership with _Diabetes Forecast_ is
US$24/year (in the US, $41.93 in Canada, $39 in Mexico, $49 elsewhere,
all in US funds). The other ADA journals will set you back about
US$90-120/year apiece. A professional membership allows you to pick and
choose journals at the listed rates; if you plan to get either
_Diabetes_ or _Diabetes Care_ you should enter a professional
membership to get the best prices. Credentials are not required for a
professional membership.
The ADA takes checks, money orders, Visa, Mastercard and American
Excess. Unfortunately, orders of books from outside the USA incur an
additional $15 shipping charge.
You can get more ADA info online, including an online catalog for all
books and magazines, at
Phone numbers
1-800-232-3472
+1 703 549 1500
+1 703 549 6995 fax
or write
American Diabetes Association
Subscription Services
1660 Duke Street
Alexandria, VA 22314
USA
Edward Reid
Posting-Frequency: biweekly
Last-modified: 22 June 2002
Changes: see part 1 of the FAQ for a list of changes to all parts.
------------------------------
Subject: READ THIS FIRST
------------------------------
Subject: Table of Contents
------------------------------
Subject: How accurate is my meter?
bG (blood glucose) meters are not as accurate as the readings you get from
them imply. For example, you might think that 108 means 108 mg/dl, not 107 or
109. But in fact all meters made for home use have at least a 10-15% error
under ideal conditions. Thus you should interpret "108" as "probably between
100 and 120". (Similar considerations apply if you measure in units of
mmol/L.) This is a random error and will not be consistent from one
determination to the next. You cannot expect to get exactly the same reading
from two checks done one after the other, nor from two meters using the same
blood sample.
This is generally considered acceptable because variations in this range will
not make a major difference in treatment decisions. For example, the
difference between 100 and 120 may make no difference in how you treat
yourself, or at most might make a difference of one unit of insulin. With
present technology, more accurate meters would be much more expensive. This
expense is only justified in research work, where such accuracy might detect
small trends which could go undetected with less accurate measurements.
This discussion applies to ideal conditions. The error may be increased by
poor or missing calibration, temperatures outside the intended range,
outdated strips, improper technique, poor timing, insufficient sample size,
contamination, and probably other factors. Contamination is especially
serious since it can happen so easily and is likely to result in an overdose
of insulin. Glucose is found in fruits, juices, sodas, and many other foods.
Even a smidgen can seriously alter a reading.
When comparing meter readings with lab results, also note that plasma readings
are 15% higher than whole blood, and that capillary blood gives different
readings from venous blood.
Visually read strips are slightly less accurate than meters, with an error
rate around 20-25%.
For some meters, strips are available from manufacturers other than the meter
manufacturer. Some m.h.d. readers have compared the strips side-by-side and
found those from one manufacturer to read consistently lower than the strips
from another. The differences are not likely to make a significant difference
in your treatment, but are large enough to be noticeable and possibly
confusing. For this reason it is not a good idea to change strip
manufacturers without comparing the readings from one with the readings from
the other.
I've seen no such direct comparison of meters, but the possibility exists that
some meters might read consistently lower than others. Be careful when
changing meters.
By "error rate" I mean twice the standard deviation from the mean. An error
rate of 15% says that about 95% of the readings will be within 15% of the
actual value.
------------------------------
Subject: Ouch! The cost of blood glucose measurement strips hurts my wallet!
The cost of blood glucose measurement strips is a complex interaction
of R&D costs, manufacturing costs, marketing strategy, insurance
practices, and undoubtedly other factors. You can ask on the net if you
want; you'll get lots of comments but no answers.
There are a few of ways of reducing the cost of blood glucose
monitoring.
One is to seek out the best price for the strips; large stores such as
FEDCO often have good prices, as do some mail order suppliers (see mail
order section).
A second way is to choose a meter with lower cost strips. Your health
care team may be familiar with and prefer a particular meter, but it's
not likely that they considered cost in making their choice. If you
insist that you need a lower cost system, they should be willing to
work with you. All meters now on the market are adequately accurate for
home use.
A third way is to use visually read strips (Chemstrip bG and a couple of
lesser known brands) and cut them in half or even in thirds. Do the
cutting carefully with a pair of strong, *clean* scissors, and get the
strips back into the vial as quickly as possible. Some manufacturers
claim this procedure will cause problems, but those who have used the
technique report that it works well. Visually read strips are slightly
less accurate than meters. However, as of 1998, prices on visually read
strips are relatively high, and you will have to consider whether the
projected savings are worth the time to cut strips and the loss of the
convenience which meters give.
Do *not* cut strips when using them in meters. The results will be
totally incorrect.
Most discussion on m.h.d of the cost of blood glucose measurement strips
has centered on the US. I'm not sure why, though a good guess is that
differences in health care systems and national policies make this
issue more critical to the individual patient in the US. There is no
dearth of non-US participants on m.h.d.
------------------------------
Subject: What do meters cost?
The flip side of expensive blood glucose measurement strips is that
the manufacturers virtually (and sometimes literally) give away the
meters to hook you on their strips. Don't pay full price for a
meter; look for discounts, rebates, and giveaways. For example, as
of this writing I'm looking at a catalog that shows a Glucometer 3
for US$45, with a US$30 manufacturer's rebate *and* a US$30 trade-in
allowance if you already have a competing meter -- which means you
make US$15. There are similar deals on other meters.
But make sure you consider the cost of strips as well as the cost of
meters, and find out which your insurance will pay for. The most
fully featured meters, such as the One Touch II, don't have such
widely advertised deals, though you can probably find ways of
getting them at discount.
If you have insurance that pays for strips but not for the meter,
you should not have to pay anything for the meter. If it's worth the
time to you, call the meter manufacturers' customer service
departments or the mail order outfits (see "Where can I mail order
XYZ?" in part 4, Sources). They will find a way to get you the meter
for free.
As with strips, this discussion of costs applies to the US, and
there has been little discussion of meter costs outside the US on
m.h.d., probably because fewer tradeoffs are available in most
countries.
An Australian correspondent notes a much narrower choice and higher
cost of meters there, but subsidized (pardon, subsidised)
measurement strips.
In Britain, strips are covered by the National Health Service, but
meters may be expensive. However I've also heard of a limited-time
One Touch program providing a full refund for the meter if you
submit the strip wrappers. Likely other companies will compete.
Elsewhere? Please post. It's likely that the situation is continuing
to change rapidly, so if the cost of the meter is painful for you,
investigate other options before paying full price -- wherever you
live.
------------------------------
Subject: Comparing blood glucose meters
Here are three ways of getting a list of the specs for most currently
available meters.
1) Call Hospital Center Pharmacy in Boston, 1-800-824-2401 (US only).
They have a chart which they will gladly send you.
2) The ADA publishes a Buyer's Guide to Diabetes Products once a
year in the Resource Guide, a supplement to the January isue of
Diabetes Forecast. As of January 2000, the latest is the Resource
Guide 2000. The meters section lists meters and features in a table.
The ADA does not recommend one meter over another, but does include
some tips on choosing a meter.
3) The ADA has this same Buyer's Guide information online at
http://diabetes.org/diabetesforecast/2000BuyersGuide/default.asp
This URL will change in future years.
The caveat is that you must be patient. The table is a huge scanned
graphic rather than text. It will take about ten minutes to download
all the graphics on the page on a good 28.8 modem connection, and
possibly much longer.
------------------------------
Subject: How can I download data from my meter?
You can get a cable to hook the One Touch II and Profile meters to a PC
from the meter manufacturer, LifeScan. The cable includes some
electronics, not just a cable, so you probably don't want to make your
own -- but if you do, check out the schematics at either of these
sites:
http://www.sci.fi/~keytech/otcable.html
http://www.geocities.com/SiliconValley/Haven/5371/indexe.html
In the US the cable is free (or nearly so -- some mhd readers report
being quoted a small fee). Elsewhere, LifeScan lets each international
office set its own policy on cable distribution, and some are charging
substantial fees. North American telephone numbers are:
U.S.A. 1-800-227-8862
+1 408 263 9789
Canada 1-800-663-5521
LifeScan provides some software for downloading the data. The more
recent versions provide considerable additional analysis.
A wide variety of other software is available as of 1998. I can't keep
up with it. See Michael Wolfe's companion posting on software.
Most meter makers now offer some software to be used with their meters.
Third party software is more abundant for the One Touch meters because
LifeScan, unlike other makers, publishes the download protocol. You can
ask them to send you a copy of the specs, or download it from
One Touch II: ftp://vic.cc.purdue.edu/pub/lifescan.ot2
One Touch Profile: ftp://vic.cc.purdue.edu/pub/lifescan.pro
Since these are simple tty-oriented protocols, you can download the raw
data from your meter using a basic telecom program such as Kermit or
ZTerm.
I'll mention just one piece of software here. Vic Abell
<abe(AT)purdue.edu> has long provided a simple free DOS program to
download and analyze One Touch II and Profile data. Vic posts update
announcements to misc.health.diabetes and has been known to support his
program via the newsgroup. TOUCH2 interfaces to the RS-232 data port of
the One Touch, downloads the data on command, and provides a variety of
analytical displays. It's available in a couple of compressed forms via
anonymous ftp from vic.cc.purdue.edu in the /pub directory, or using a
web browser,
------------------------------
Subject: I've heard of a non-invasive bG meter -- the Dream Beam?
***The following information is incomplete, as another company has introduced
a non-invasive meter for about $8000. It has been discussed in the
newsgroup. Rumors of other non-invasive (and "non-evasive") meters abound.
I won't be trying to keep this section up to date until the situation
stabilizes. ***
There is at least one development project in hot pursuit of a bG monitor
which operates by shining light through flesh (through the thumbnail in one
case) and analyzing the light that passes through. Glucose doesn't affect
light much differently from many other substances in the body, so this is not
an easy task. Some field trials have been done, but the developers have a way
to go to reach acceptable accuracy. A successful product is far from
guaranteed, and may be several years away if it arrives at all.
One estimate is that such a meter might cost about US$1000. Assuming the
per-check cost is zero, this would pay for itself in 1-2 years for many
patients. Look for the insurance companies to throw up some roadblock to
achieving these savings, at least in the US.
------------------------------
Subject: What's HbA1c and what's it mean?
Hb = hemoglobin, the compound in the red blood cells that transports
oxygen. Hemoglobin occurs in several variants; the one which composes
about 90% of the total is known as hemoglobin A. A1c is a specific
subtype of hemoglobin A. The 1 is actually a subscript to the A, and
the c is a subscript to the 1. "Hemoglobin" is also spelled
"haemoglobin", depending on your geographic allegiance.
Glucose binds slowly to hemoglobin A, forming the A1c subtype. The
reverse reaction, or decomposition, proceeds relatively slowly, so any
buildup persists for roughly 4 weeks. Because of the reverse reaction,
the actual HbA1c level is strongly weighted toward the present. Some of
the HbA1c is also removed when erythrocytes (red blood cells) are
recycled after their normal lifetime of about 90-120 days. These
factors combine so that the HbA1c level represents the average bG level
of approximately the past 4 weeks, strongly weighted toward the most
recent 2 weeks. It is almost entirely insensitive to bG levels more
than 4 weeks previous.
In non-diabetic persons, the formation, decomposition and destruction of
HbA1c reach a steady state with about 3.0% to 6.5% of the hemoglobin
being the A1c subtype. Most diabetic individuals have a higher average
bG level than non-diabetics, resulting in a higher HbA1c level. The
actual HbA1c level can be used as an indicator of the average recent bG
level. This in turn indicates the possible level of glycation damage to
tissues, and thus of diabetic complications, if continued for years.
Interpreting HbA1c values can be tricky for several reasons. See the
following section for more details.
------------------------------
Subject: Why is interpreting HbA1c values tricky?
Interpreting HbA1c values is tricky for several reasons: differing lab
measurements, variation among individuals, and misapprehension of the
relevant timeframe.
First trick: several different lab measurements have been introduced
over the past 15 years, measuring slightly different subtypes with
different limits for normal values and thus different interpretive
scales.
A National Glycohemoglobin Standardization Program began in 1996,
sponsored by the American Diabetes Association and others. See
reference 1. This program certifies HbA1c assays which conform to the
method used in the DCCT. However, as of 1998 other versions are still
in use in many places, both in the US and elsewhere. When you get a lab
result, be sure to look at what the lab considers to be the normal
range. Most discussion of HbA1c values in m.h.d appears to be based on
the DCCT, where the normal range is approximately 3.0-6.1%. Caveat
lector. (See part 5, Research, of this FAQ for more information on the
DCCT, the Diabetes Control and Complications Trial.)
Second trick: HbA1c levels appear to vary by up to 1.0% among
individuals with the same average bG. See reference 2.
This is very recent research and its implications are not yet clear. The
actual reaction rates governing the formation of HbA1c may vary among
individuals. Some of the variation may be due to differences in
erythrocyte (red blood cell) survival times -- the rough 90-120 day
range noted earlier -- although other work limits this to a small part
of the total variation (see reference 5). Variations in the HbA1c
formation rate may or may not correlate with the rate of damage to
other tissues.
While we await further research, we can only say that differences of
1.0% from one individual to another may not be meaningful.
Although HbA1c varies among individuals with the same average bG, it is
very stable for any given individual. Thus a change of 1.0% in your own
HbA1c is definitely meaningful.
Third and final trick: most medical professionals have been given
incorrect information about the timeframe which HbA1c represents.
Even textbooks normally state the 90-120 day average, as does the
American Diabetes Association in its Position Statement on Tests of
Glycemia in Diabetes (see reference 1).
The longer estimate is based on the assumption that the conversion of
hemoglobin A to HbA1c is essentially irreversible. This was a
reasonable assumption before the reaction rates were actually measured.
See the following section for information about the research which
measured the reaction rates and simulated the consequences.
See the following section for the references mentioned above.
------------------------------
Subject: Who determined the HbA1c reaction rates and the consequences?
In the early 1980s, Henrik Mortensen and colleagues at Glostrup
University Hospital, in Denmark, measured the reaction rates in vitro.
Their results showed the assumption of irreversibility to be untrue. In
fact the reverse reaction (HbA1c to HbA and glucose) proceeds at about
1/8 the rate of the forward reaction, which is very far from
irreversible. Mortensen et alia also built a biokinetic model based on
the measurements, and validated the model by comparing its predictions
to actual patients. See references 3-5.
Among other things, Mortensen's work shows that after a change in
average bG level, the HbA1c level restabilizes after about 4 weeks.
This has several consequences. Clinically, the most important are
these:
First, the HbA1c is an exponentially weighted average of blood glucose
levels from the preceding 4 weeks, with the most recent 2 weeks being
by far the most important.
Second, measuring HbA1c less often than monthly results in unmonitored
gaps between measurements. To use HbA1c as a continuous monitoring
tool, you need to check it at least once a month.
Third, it is worthwhile checking the HbA1c of newly diagnosed patients
as often as once a week to determine the effectiveness of the newly
imposed treatment.
Reference 1: American Diabetes Association, Tests of Glycemia in
Diabetes, Diabetes Care 23:S80-S82, January 2000 Supplement 1.
Available on the web at
http://journal.diabetes.org/FullText/Supplements/DiabetesCare/Supplement100/s80.htm.
or check the home page at http://diabetes.org and follow the link to
"Clinical Practice Recommendations".
Reference 2: Kilpatrick ES, Maylor PW, Keevil BG: Biological Variation
of Glycated Hemoglobin. Diabetes Care 21:261-264, February 1998.
Available on the web at
http://www.diabetes.org/diabetescare/1998-02/PG261.htm.
Reference 3: Mortensen HB, Christophersen C: Glucosylation of human
haemoglobin a in red blood cells studied in vitro. Kinetics of the
formation and dissociation of haemoglobin A1c. Clinica Chimica Acta
134:317-326, 15 November 1983.
Reference 4: Mortensen HB, Volund A, Christophersen C: Glucosylation of
human haemoglobin A. Dynamic variation in HbA1c described by a
biokinetic model. Clinica Chimica Acta 136:75-81, 16 January 1984.
Reference 5: Mortensen HB, Volund A: Application of a biokinetic model
for prediction and assessment of glycated haemoglobins in diabetic
patients. Scandinavian Journal of Clinical and Laboratory Investigation
48:595-602, October 1988.
------------------------------
Subject: HbA1c by mail
You may find it cheaper and/or more convenient to have your HbA1c
measurements done by mail -- and you collect the sample by fingerstick.
Diabetes Technologies provides a "Accu-Base A1c (tm) Hemoglobin A1c
Sample Collection Kit" and instructions for mailing the sample to a lab
which cooperates with them. The kit, which is sufficient to collect
three samples, costs $36.95 plus shipping, and the lab charges $10 per
test, for a total cost of under $25 per test. You can also buy the kit
for a single sample collection. They normally ask for a doctor's
prescription before sending the kit -- not because it's required but
because they want to make sure to keep the doctors in the loop. Unhappy
doctors are not good for their business.
A personal note: I have used the Diabetes Technologies kit, and a
predecessor supplied by Diabetes Support Systems, since 1996. Without
this service, I probably would have had at most one HbA1c measurement
per year due to the cost and the inconvenience of visiting the lab or
doctor's office -- and I really needed the tests at times. I plan to
continue using the service.
The procedure is simple: take a capillary tube from a vial and hold it
with a provided clip. Stick your finger (using a one-use lancet they
provide, if you wish) and touch the end of the tube to the drop until
the tube is full -- a fraction of a second usually. Drop the tube into
a small vial with fluid in it (pre-filled) and shake for a few seconds.
Fill out a little paperwork. Pack the vial in a Biopack, padding and
package, all provided and even prestamped. Drop it in the mail. You
provide: writing pen and blood.
The lab analyzes the sample using HPLC (high performance liquid
chromotography). This is the same as the major labs use. In other
words, SmithKline takes an entire vial of blood and uses one drop.
Diabetes Technologies is in Thomasville, GA. Their phone number is
888-872-2443.
Express-Med makes a kit which I believe is similar, but I haven't used
it. Their literature is a bit unclear on the cost, but I think it's
$17, all inclusive. Their test requires a small drop of blood, but the
literature does not describe the actual procedure. For more information
and forms, call 1-888-834-2212.
Becton-Dickinson (BD) was advertising a HbA1c kit in 1998. However, the
last time I spoke with someone there, they were only distributing it
through health care organizations (such as HMOs) and plans for
individual sales were indefinite.
Note that the fact that I describe the Diabetes Technologies kit more
thoroughly than any other option is simply because I have personal
experience with that kit and not with any other current offerings.
------------------------------
Subject: Why is my morning bg high? What are dawn phenomenon, rebound,
and Somogyi effect?
This section is written by Charles Coughran <ccoughran(AT)ucsd.edu>.
There are three main causes of high morning fasting bg. In decreasing order of
probability they are insufficient insulin, dawn phenomenon, and Somogyi
effect (aka rebound). Insufficient or waning insulin is simple. If the
effective duration of intermediate or long acting insulin ends sometime
during the night, the relative level of circulating insulin will be too low,
and your blood sugars will rise.
Dawn phenomenon refers to increased glucose production and insulin resistance
brought on by the release of counterregulatory hormones in the early morning
hours near waking. It happens in normal people as well as in diabetics; in
nondiabetics it shows up as measurably increased insulin secretion around
dawn. Dawn phenomenon is variable in strength both within the population and
over time in individuals. It can show up as either high fasting glucose
levels or an increased insulin requirement to cover breakfast compared to
equivalent meals at other times of day.
Somogyi effect refers to a rebound in bg after nocturnal hypoglycemia which
occurs during sleep with the patient not experiencing any symptoms. The
hypoglycemia triggers the release of counterregulatory hormones. Somgoyi
effect appears to be less prevalent than previously thought. While it does
occur, some episodes of hyperglycemia following hypoglycemia are actually
waning insulin levels following an insulin peak with medium acting insulin.
This can be difficult to sort out.
The best way to sort it out is to test every couple of hours from bedtime to
morning.
If your bg rises all, or much of the night, it is a lack of circulating
insulin.
If it is stable all night, but rises sharply sometime before you wake in
the morning, it is dawn phenomenon.
If your bg declines to the point of a hypoglycemic reaction, it is
*possibly* Somogyi effect.
You may have to test on several nights to nail the problem. Once you have
figured out the problem you and your doctor can discuss changes in your
insulin regimen to correct it. The answer depends critically on your
particular circumstances.
Mayer Davidson, in _Diabetes Mellitus: Diagnosis and Treatment_ (p 252 in the
3rd edition) says that Somogyi effect rarely causes fasting hyperglycemia,
and cites studies.
Edward Reid
Posting-Frequency: biweekly
Last-modified: 22 June 2002
Changes: see part 1 of the FAQ for a list of changes to all parts.
------------------------------
Subject: READ THIS FIRST
------------------------------
Subject: Table of Contents
------------------------------
Subject: My diabetic father isn't taking care of himself. What can I do?
We'll assume your father has type 2 diabetes. See separate section for
definition of types.
Type 2 diabetics, and those who care for them, are in a difficult situation.
Type 2 strikes late in life, so personal habits and patterns are already
formed and solidly engrained. Yet in most cases those habits and patterns are
exactly what must be changed if a newly-diagnosed diabetic is to care
properly for his or her health. This is a difficult psychological problem.
The cornerstones for treating type 2 diabetes are exercise, weight control,
and diet. A high percentage of type 2 patients who apply these therapies
assiduously can control the disease with these therapies alone, without
insulin or oral hypoglycemic drugs. Naturally these are also some of the most
difficult aspects of life to change. There can be no single or simple answer
of how to help or encourage a particular individual find a combination of
therapies which not only controls the disease but also is psychologically
acceptable and which can be incorporated as a lifetime pattern. Helping
depends on knowing the individual's habits, patterns, motivations, desires,
likes and dislikes, and working with all the existing conditions and
everything brought forward from past life.
Doctors and other health care professionals have a choice in treating
patients with type 2 diabetes. They can prescribe drugs (oral hypoglycemics)
and insulin, or they can try to get their patients to make the difficult
lifestyle changes described above. (Many patients need both.) The latter
effort is time consuming and often frustrating, as doctors too often see
patients failing to make any change at all.
Friends and family can help by learning about type 2 diabetes, and doing what
you can to encourage your loved one to make diet and lifestyle changes. If
this supports the plan a treatment team is urging the patient to follow, you
will add your support for difficult changes. If the doctor (or the whole
treatment team) falls down on the educational and motivational structure, you
can fill in some of the gaps. Your effort is well spent in either case.
In particular, if a doctor has left the impression that drugs and insulin are
the only treatments, make sure to counter that impression with information
about the value of exercise, diet, and weight control.
At the same time, it's important to remember that needing oral hypoglycemics
and/or insulin injections as additional tools isn't failure. On the contrary,
a patient who's been actively involved in self treatment already has an
excellent chance of using these additional tools successfully. Those who have
learned to use the exercise - weight control - diet triumvirate will also be
able to utilize insulin and oral drugs as additional treatments when needed.
Choose the appropriate tools and use them effectively.
These treatment choices can interact in positive ways as well. Bringing blood
glucose under control often increases the body's sensitivity to insulin. So
ironically, using insulin may decrease the need for insulin. This is a
positive change which can then be reinforced by the other, interacting
treatments.
You will need far more information than is appropriate for a Usenet FAQ
panel. As a start, call the ADA (see ADA section), get a subscription to
_Diabetes Forecast_ (see journals), and visit a university library and browse
in the diabetes section in the stacks.
Beyond the generalizations above, a few specifics are usually of value:
Set a good example in your own life. Exercise and eat a good diet.
The recommendations for diabetics are healthy choices for anyone.
Share your example. Serve a tasty, low-fat diet to family and friends
when they are your guests.
Suggest joint activities. Suggest a walk instead of watching a
ball game.
Make sure your diet and activities are visibly enjoyable so your
guests will accept your invitiation to join you.
------------------------------
Subject: Managing adolescence, including the adult forms
Adolescents have special problems in managing diabetes. These include a
variety of physiological problems related to puberty and rapid growth, social
problems related to growing up and the general social pressures of adolescent
life, and the psychological turmoil caused by the expectations of others. I'm
here today to talk about (hey, hold the eggs and tomatoes) expectations.
Actually, this all applies to adults as well, though the subtle points may
differ.
The most important thing to remember, for the adolescent, the parent, and the
health care provider, is
All Blood Glucose Measurements Are Good.
There Are No Bad Blood Glucose Readings.
If that doesn't sound right, then please take two steps. First, learn why it
is true. Then chant it like a mantra until you internalize it, so that you
never give off the slightest vibes to the contrary.
Why is it true?
There are two kinds of adolescents (to simplify life enormously): those who
rebel and those who want to please. Ironically, the rebellious are probably
easier to deal with in treating diabetes. "So my blood sugar is 350, so
what?" Bad? No, that's good: you know what's going on, and so does your
child. The point of blood glucose measurement is to respond -- not to be good
or bad -- and only with an accurate report can you and the patient respond.
[Compulsory digression: 350 mg/dl = 20.0 mmol/L.]
Look what can happen to the eager-to-please child:
Child: My blood sugar is 350.
Adult: Oh, that's awful! You must try to be better!
[next time:]
Child: My blood sugar is ... um [to self: I must be good] 140 ...
Adult: Oh, that's great!
In short order, the log book looks great but the HbA1c doesn't jibe.
This all happens with the best of intentions from all parties. The child is
trying to please, and is behaving in exactly the ways that elicit approval.
The adult is trying to care for the child's health in the most natural ways.
And the result is one that neither desires.
Thus the positive mantra to replace the half-negative one above:
All Blood Glucose Measurements Are Good.
Responding To Blood Glucose Readings Is Good.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
An excellent article entitled "Insulin Therapy in the Last Decade: A
Pediatric Perspective", by Julio Santiago, MD, of the St. Louis Children's
Hospital and the Washington University School of Medicine in St. Louis,
Missouri, appears in _Diabetes Care_, volume 16 supplement 3, December 1993,
pp. 143-154. The article discusses many aspects of treating pediatric
diabetes. Santiago spends several pages discussing how to establish realistic
and honest approaches to self-monitoring. I highly recommend the article.
------------------------------
Subject: So-and-so eats sugar! Isn't that poison for diabetics?
This is asked from both sides: the non-diabetic who doesn't understand
diabetes, and the diabetic who gets tired of hearing "I won't put any sugar
on the table" etc etc ad nauseum.
Diabetics should eat a high-quality, healthy diet very similar to that
recommended for everyone. This will include some sugar, and research
indicates that obtaining a moderate amount of carbohydrates in the form of
sugar makes little or no difference in controlling blood glucose levels. There
isn't room here to describe all the aspects of diabetes treatment that make
this so.
No one has suggested a really good, uniformly satisfying answer to the public
know-alls who insist they know more than you do. Feel free to add to this
list:
That was true before insulin treatment became available in 1922.
Fat is more dangerous than sugar because diabetics have a three-fold
higher risk of heart disease.
The whole point of injecting insulin is to balance carbohydrate intake.
All carbohydrates are converted to sugar in the digestive tract anyway.
------------------------------
Subject: Insulin nomenclature
The major types of insulin have both generic designations and brand names
used by the manufacturers. Most of the brand names are close enough to the
generic ones that the correspondence is obvious. Novo uses totally different
names. In those parts of the world where Novo has most of the market, the
Novo brand names are used in place of the generic names. To facilitate
communication between Novo users and others, here is the correspondence:
Generic Novo May also be known as
------- ---- --------------------
Regular Actrapid Soluble
NPH Protophane Isophane
Lente Monotard
Ultralente Ultratard Zn (Zinc suspension)
The recently developed lispro (generic name) insulin is sold as Humalog by
Eli Lilly. Novo has no comparable insulin as of July 1996, although they
undoubtedly have research in progress.
------------------------------
Subject: What is Humalog / LysPro / lispro / ultrafast insulin?
Except as otherwise noted, this info comes from an article on p396 of the
March 1994 _Diabetes_ by researchers at Eli Lilly.
Insulin is a protein. Proteins consist of sequences of amino acids. Human
insulin has the amino acid lysine at position B28 and proline at position
B29.
Insulin molecules naturally pair off (like people) and combine into dimers.
The dimers interact with small amounts of zinc and combine into hexamers, the
form sold as "regular" insulin.
From another source, now forgotten: the time required to disassociate the
hexamer into the dimer, and then the dimer into the monomer so that it
can be absorbed, is the main reason for the delay in the action of regular
insulin and the reason for injecting it 30 to 45 minutes before meals.
Switching the B28 and B29 positions on the protein has no effect on the
normal activity of the insulin but inhibits the formation of the dimer and
the hexamer. Thus the insulin is in monomeric form when injected and can be
absorbed immediately.
The name LysPro comes from the names of the amino acids, lysine and proline,
that occupy the swapped positions. According to an article in the August 1996
Diabetes Forecast, the spelling 'lispro' is now preferred.
Challenges in the development include the biochemical process for swapping the
amino acids, and making the result reasonably stable in the monomeric form.
From another source, now forgotten: US FDA approval was not automatic, since
the insulin molecule has been modified. In fact, several other amino acid
exchanges have been tried and met with unacceptable side effects.
Some points from the article in the August 1996 Diabetes Forecast:
Patients with gastroparesis, or taking acarbose, should be careful with
lispro. Gastroparesis is a condition caused by neuropathy which causes
the stomach to empty slowly and erratically. (See the section on
gastroparesis later in this section.) Acarbose is a drug which slows
the absorption of carbohydrates from the intestine. Either may result
in lispro insulin acting too quickly.
Response to lispro is variable. Some patients love it, others hate it.
On the average, it does not change bg control either for better or for
worse, but some patients definitely find it one or the other. Eli Lilly
is promoting lispro for convenience, not for better control.
Doctors and patients are still experimenting with the best regimens for
using lispro insulin. "Best" clearly varies from one patient to another.
Typically lispro insulin is injected very close to mealtime.
An obvious concern is that hypoglycemic reactions might be more common with a
faster acting insulin. A paper presented at the 1996 ADA Scientific Papers
conference studied this possibility:
Reducing the Incidence of Hypoglycemia with a Novel Insulin Formulation
J. Anderson, R. Brunelle, A Pfeutzner et al.
Indianapoils, IN and Bad Homberg, Germany
In fact, they found the rate of hypoglycemic incidents slightly lower among
those using lispro insulin. They found no difference on most other measures,
including especially HbA1c. I've only seen the abstract of the paper, so I
know nothing about their methodology. (They also state the lispro forms
hexamers just like regular insulin but that the hexamers dissociate much more
quickly. I don't know who to believe, but from a practical point of view it
doesn't matter.)
------------------------------
Subject: Travelling with insulin
Insulin does not need to be kept cold.
Insulin is stable at body temperature. This is not surprising when you
realize that the beta cells often store the insulin they produce for
days before releasing it. (Specifically, according to Jens Brange's
_Stability of Insulin_, Regular/Actrapid insulin stored at 40C will
lose 5% of its potency after 14 weeks.)
A general guide to how long it is safe to store insulin at various
temperatures:
Refrigerated a few years
Room temperature several months
Body temperature a few weeks
Do not allow insulin to freeze. Do not expose insulin to temperatures
significantly above body temperature. I don't know how much heat is
required to destroy insulin, but leaving it in a closed car in the sun
would be a very bad idea. (Two readers have reported that solidly
frozen and rethawed regular insulin works just fine. I've been unable
to locate any studies documenting the degradation of insulin at extreme
temperatures.)
Short of such extremes, degradation is gradual. You should always be
alert for gradual changes in your blood glucose anyway, since
individual sensitivity to insulin changes over time for reasons
unknown. Your normal dosage adjustments will handle minor degradation
that might occur, say, from keeping insulin in a very hot room for
several weeks.
So why do drugstores (pharmacies) keep insulin refrigerated, and why are
"insulin cold packs" advertised? The drugstores are mosty just
following standard procedures. For them, it's a simple precaution not
worth violating..
As for cold packs, as long as anyone thinks they are needed, someone
will sell them. As noted, you do need to protect insulin from extremes
of temperature, and the cold packs can help at both extremes. In many
situations it may be just as effective to pack the insulin next to a
bottle of water, especially during outdoor activities when you are
carrying water anyway.
Always keep your insulin with you! Keep all your medical supplies with
you. Never pack them in checked luggage. Luggage may sit outside in hot
sun or freezing rain. If you are delayed, or your luggage is waylaid,
you could be without supplies packed in luggage.
Meter manufacturers recommend keeping meters and strips from freezing
and extreme heat.
------------------------------
Subject: Injectors: Syringe and lancet reuse and disposal
Disposable syringes can be safely reused as long as you take reasonable
precautions. Recap both ends between uses, and discard the syringe if
dropped, dirty, or damaged (especially if the needle is bent). Discard
it when it becomes uncomfortable to use. This varies a great deal,
being half a dozen uses for some patients and several dozen uses for
others. Comfort depends far less on sharpness than on the silicone
coating applied to the needle at manufacture. Never wipe the needle
with alcohol, as this will remove the silicone coating.
Lancets can also be reused safely with the same caveats.
Syringe disposal has proven controversial. If you want to be
conservative, buy a needle clipper, get a hard plastic bottle designed
for medical waste to put the syringes in, and take the full bottle to a
facility approved for handling medical waste. Your doctor's office, a
local hospital, or a pharmacy may be able to handle it for you.
Intermediate positions use one of these techniques. At the least
conservative, cap the needle carefully and discard in trash which will
not be subject to illicit searching and possible abuse. If you have
trouble capping the needle without sticking yourself, definitely get a
bottle to drop the uncapped syringes in; a bleach bottle may be
adequate.
Local or state regulations apply in many places and limit your choices.
Know the laws for your area! Where sharps containers are required, the
pharmacy where you purchase the container will probably dispose of the
full container for you.
------------------------------
Subject: Injectors: Pens
A pen injector is a device that holds a small vial of insulin and a
disposable needle, and injects an amount measured with a dial.
Advantages include being compact, convenient, easy to use circumspectly
in public, and accurate and simple in dose measurement. The pen device
clicks for each unit (or two depending on the manufacturer) dialed;
this can help those with impaired vision.
Some pen units only allow setting a multiple of two units of insulin,
which many find inadequate. Get a model which measures a multiple of
one unit, which should be easy to find among current models.
The primary disadvantage is cost, up to twice as much per unit of
insulin compared with standard vials. The special vials may be
difficult to obtain in remote areas, and widespread shortages have
occurred occasionally. Falling back to a standard syringe is always an
option.
Also, the special vial can be refilled from a standard vial using a
syringe, making sure the rubber stopper is not damaged, though the
manufacturer will not recommend this. If you do refill, make sure to
use the same concentration of insulin. This is not a problem in the US,
where only U100 concentration is used. In some parts of the world, U40
concentration is common, but pen refills are always U100. Make sure to
match the concentration.
Pens are more popular in Europe than in the US, but are being heavily
promoted in the US.
------------------------------
Subject: Injectors: Jets
A jet injector uses no needles, but instead squirts the substance being
injected through a narrow orifice under high pressure, producing a fine
stream which penetrates the skin as easily as a needle. Jets are popular with
anyone who is simply scared of needles, for any reason. The jet disperses the
insulin more than a needle does, which probably results in faster absorption.
This can be an advantage or a disadvantage, and requires careful monitoring
when first used. Technique is just as important as with needles, so jets are
no more appropriate than needles for small children. If a jet is used to
avoid needles, equipment failure forcing a fallback to needles may be
traumatic. High cost is a major factor.
------------------------------
Subject: Insulin pumps
An insulin pump provides a Continuous Subcutaneous Insulin Infusion, or CSII,
via an indwelling needle or catheter. That is, a small needle (similar to
those on insulin syringes) or tube is inserted through the skin and fixed in
place for two or three days at a time. An external box pumps insulin through
the needle steadily.
Pumps don't solve all the problems of treating diabetes for two main reasons:
1) The infusion is still subcutaneous, so the insulin still must be
absorbed before it can be used. Insulin from the pancreas goes directly
into the bloodstream and takes effect much more quickly.
2) Current pumps are open-loop -- that is, there is no feedback from blood
glucose (bG) to the pump. The patient must still self-monitor bG and
program the pump.
Nonetheless, many patients get much better results with a pump than from
intensive therapy without a pump, and those patients tend to be extremely
happy with the pump. It isn't clear at present how to decide whether a given
patient should use a pump. Different studies have obtained varying results,
ranging from 85% success to 85% dropout! Unfortunately, no studies seem to
have been done since the mid-1980s, and it is likely that the pumps and pump
therapy have become much more consistently successful since then. A few
important factors seem clear, though:
1) Motivation. A pump takes extra effort and attention.
2) Knowledge. If you aren't already familiar with intensive therapy,
think more than twice before jumping for a pump. You should
probably try intensive therapy with multiple injections first.
3) Treatment team. Successful users are backed by teams of physicians
and educators who are experienced *with pumps*. Don't try a pump on
your own (the manufacturers won't let you anyway), and don't try it
with inexperienced providers -- these are recipes for unnecessary
failure.
4) Funding. Pumps represent a nontrivial capital outlay. If you don't
have insurance or other public programs that will pay for the pump,
you will need personal financial resources.
Most or all pump manufacturers allow a trial period, so you can try a pump
without financial risk. You will probably know fairly soon whether you want
to continue with the pump.
A long discussion about many aspects of pumps is posted monthly at the same
time as this FAQ. See the section "Where's the FAQ?" for retrieval
information. The insulin pump discussion was developed and is maintained by
Jim Summers <summers(AT)cs.utah.edu>.
------------------------------
Subject: Type 1 cures -- beta cell implants
Beta cells can be isolated and implanted, requiring only outpatient surgery
for implantation. But foreign beta cells are quickly rejected without
immunosuppressant drugs. Even with the recent advances in drugs, especially
cyclosporin, using immunosuppressants is much more dangerous than living with
diabetes. As a result, beta cell implantation is not currently used to treat
diabetes.
Current research is investigating two general methods of implanting beta
cells without the use of immunosuppressant drugs. The first (immunoisolation)
encapsulates the beta cells within a barrier so that nutrients, glucose, and
insulin can pass freely through the barrier but the proteins which provoke
the immune response, and the cells which respond, cannot pass. The second
(immunoalteration) involves altering the proteins on the surface of the cells
which provoke the immune response. The first human trial began early in 1993
on immunoisolated beta cells, and human trials were scheduled to begin late
in 1993 on immunoaltered beta cells. (As of early 1997, I haven't had the
opportunity to try to locate the followup to these trials.)
An article in the Journal of Clinical Investigation, September 1996,
describes a successful experiment which implanted immunoisolated porcine
(pig) islets into monkeys. An accompanying editorial describes the state of
islet transplantation. Both are online in full, linked from the issue
contents page at
http://www.jci.org/content/vol98/issue6/
In early 2000, a lot of hype appeared about the "Edmonton protocol" trials.
While an important step, this is still only a small step on a long journey.
They made improvements in technique and graft survival, but no progress on
the serious problems of beta cell supply (each patient needed beta cells
from two cadaver donors) or of immunosuppressant use (they used drugs,
albeit carefully).
Don't expect these treatments to be available on a standard basis any time
soon. I've been reading about this research since the mid-1970s, and the
results are always just around the corner. Serious problems remain to be
solved: safety of the immunoisolated implants, long-term survival, ability to
use beta cells from non-human species or grow usable cells for grafting in
the laboratory, perfection of both techniques -- all
these must be resolved before beta cell implantation moves beyond the
experimental stage. Other problems will likely be encountered along the way,
since this is cutting edge medical research. I'll be surprised if it gets out
of the lab before the year 2005; 2015 is probably a better guess. And it may
fail -- it's always possible that unsolvable problems will yet arise.
Finally, it's not yet clear that even completely normal bG profiles will cure
all the problems of type 1 diabetes. Some may be related to the autoimmune
reaction that is the immediate cause of diabetes. This question cannot be
answered until it is possible to normalize bG levels for a period of many
years.
------------------------------
Subject: Type 1 cures -- pancreas transplants
Whole pancreas transplants have the same rejection problems as beta
cell implants, and also require major surgery. For these reasons, whole
pancreas transplants are only used 1) in desperate cases in medical
schools with exceptional capabilities, and 2) in conjunction with
kidney transplants.
Kidney transplants are (relatively) common in diabetics with advanced
complications. A kidney recipient is taking immunosuppressant drugs
anyway, and the same surgery that implants the kidney can stick in a
pancreas with little extra effort or trauma. As a result, the double
transplant is now recommended, at least for consideration, for any
diabetic patient who requires a kidney transplant.
The only disadvantage would seem to be that the pancreas donor must be
dead; whereas a living kidney donor is feasible. Even this is not
strictly true, as a kidney-plus-partial-pancreas transplant from a
living donor is possible, and the partial pancreas contains enough beta
cells to produce insulin for the recipient. However, this procedure is
seldom performed.
Combination kidney/pancreas transplants are listed in a different queue
than kidney-only. Since the number of people waiting for donor kidneys
is quite long (anywhere from a few months to seven or eight years), the
kidney/ pancreas list is often a quicker means of receiving a
transplant. For example, in January 1998 there were 38,380 people on
the UNOS [see below] registrations for a kidney transplant. There were
only 355 registrations for a pancreas transplant and 1604 registrations
for a kidney-pancreas transplant. [Based on UNOS Scientific Registry
data as of January 28, 1998.]
Kidney/pancreas transplants, while still considered experimental at some
institutions, have been approved by Blue Cross/Blue Shield in the
following centers: University of Iowa Hospitals and Clinics, Iowa City;
University of Minnesota Hospital and Clinic, Minneapolis; Ohio State
University Hospitals, Columbus; and University of Wisconsin Hospital
and Clinics, Madison. Though this is for BC/BS only, other insurance
companies may follow the BC/BS lead if pushed. [Information from January
2000. Check to see whether additional centers have been approved.]
UNOS (United Network of Organ Sharing) has a list of 124 transplant
centers that have pancreas transplant programs. For more information,
contact UNOS at (800)24-DONOR or see their web page at
(See the section on sources for additional contact info.)
The UNOS handles transplant registrations only in the USA, but can
provide contact information for organ-donation agencies around the
world. Organ allocation became a political football in the US in the
late 1990s, and the details of allocation and waiting lists may change.
The transplant mailing list is an excellent resource. See the section on
online resources: mailing lists.
(Thanks to Alexandra Bost for much of the information in this section.)
------------------------------
Subject: Type 2 cures -- barely a dream
The treatments described in the preceding sections apply only to type 1
diabetes. Type 2 diabetes is the result of insulin resistance or other forms
of improper use of insulin within the body, not in general to an absolute
lack of insulin. Type 2 patients usually have normal beta cells at the start,
with beta cell insufficiency developing later while the insulin use defects
continue. There is nothing on the horizon for type 2 diabetes with promise
comparable to that of beta cell transplants for type 1. The sequencing of the
human genome, completed in 2000, provides information for research which is
likely to help, but that is for the very long term.
This is distinct from the *treatment* of type 2 diabetes, which has improved
quite significantly even since I first wrote the above paragraph. New drugs
are available which improve insulin sensitivity. The UKPDS directly, and the
DCCT indirectly, have convinced many more doctors that intensive treatment
of type 2 diabetes is worth the trouble and expense. Support and education
programs continue to expand. The UKPDS showed clearly that medical nutrition
therapy (MNT, diet with proper medical team support) helps type 2 diabetics
greatly even without weight loss, and so more doctors are providing the
necessary aid.
But all this is treatment, not cure.
------------------------------
Subject: What's a glycemic index? How can I get a GI table for foods?
The glycemic index, or GI, is a measure of how a given food affects
blood glucose (bG). Some complex carbohydrates affect bG much more
drastically than others. Some, such as white bread, affect bG even more
than sugar (sucrose).
This was quite a surprise when the research was first published in 1981.
It really should not have been such a surprise. "Sugar", meaning
sucrose, decomposes in the gut to equal parts of glucose and fructose.
Fructose, as expected, has only a small effect on bG. Even
professionals, it turns out, were swayed in their thinking by the evil
charm of the word "sugar" and failed to take into account the
differences among the many kinds of sugar found in foods.
To use the glycemic index in a real-life diet, you must combine the GI
of various foods using a weighted average. Rick Mendosa's article (see
below) has information on simple calculations for mixed meals, which
recent research has shown to be reliable.
It remains difficult to predict the GI of high fat meals because of the
multiple affects of the fat, especially the way it slows the gut. For
example, a baked potato has a very high GI (one of the famous,
unexpected examples), but adding butter to it lowers the GI greatly.
This is a good reason to reduce dietary fat (if you needed another
reason), since doing so makes the effect of carbohydrates more
predictable.
If you don't want to go to the effort of full GI calculations, the
important thing is to understand that foods may affect your bG profile
in ways that you wouldn't expect from categorizations such as "simple
sugar" and "complex carbohydrate". Build your knowledge about your own
response to different foods and meals by monitoring and keeping
records, and avoid assumptions.
Rick Mendosa <mendosa(AT)mendosa.com> has written an excellent and thorough
article about the glycemic index. He also maintains a glycemic index
list. I highly recommend that you check out
[Thanks to Rick for information he provided for this section.]
------------------------------
Subject: Should I take a chromium supplement?
The short answer is "no". I'll quote the ADA's longer answer, from the May
1994 _Diabetes Forecast_, p.73. The ADA's editorial board says:
Some popular books on diabetes have claimed that chromium, which is
found in many common foods such as animal meats, grains, and
brewer's yeast, is good for people with diabetes. Not so. Though
chromium supplements may benefit people who are significantly
malnourished and have an actual chromium deficiency, there is no
significant evidence that consuming extra chromium helps people
with diabetes who are even close to being well nourished.
Taken at the dosages listed on the bottle, however, chromium is not
likely to be harmful. But your money is better spent on more useful
items!
------------------------------
Subject: I beat my wife! (and other aspects of hypoglycemia)
(not yet written)
------------------------------
Subject: Does falling blood glucose feel like hypoglycemia?
Sometimes. Symptoms of hypoglycemia are divided into the adrenergic and the
neuroglycopenic. Adrenergic responses are caused by increased activity of
the autonomic nervous system and may be triggered by a rapid fall in blood
glucose (bG) or by low absolute bG levels; symptoms include
weakness
sweating
tachycardia
palpitations
tremor
nervousness
irritability (sound familiar?)
tingling of mouth and fingers
hunger
nausea or vomiting (unusual)
The autonomic nervous system activity also causes the secretion of epinephrine,
glucagon, cortisol and growth hormone. The first two are secreted rapidly and
eliminated rapidly. The second two are secreted slowly and remain active for
4-6 hours, and may cause reactive hyperglycemia.
Neuroglycopenic responses are caused by decreased activity of the central
nervous system and are triggered only by low absolute bG levels; symptoms
include
headache
hypothermia
visual disturbances
mental dullness
confusion
amnesia
seizures
coma
The above information is from Mayer Davidson's _Diabetes Mellitus: Diagnosis
and Treatment_.
Remember, as always, that individual responses vary greatly. The exact set of
symptoms encountered will vary. It's not impossible that some of the symptoms
will fall in the other category for some individuals.
------------------------------
Subject: Alcohol and Diabetes
This section provided by Peter Stockwell <peter(AT)sanger.otago.ac.nz>.
Having diabetes does not prevent the consumption of alcoholic drinks,
but there are some considerations:
- Alcohol can metabolised to produce energy and so has dietary
consequences.
- Alcohol promotes the uptake of blood glucose into liver glycogen
causing a drop in bG.
- Many alcoholic drinks contain sugar, particularly mixed drinks.
- The symptoms of drunkenness and hypoglycaemia are similar - alcohol
may mask the effects of a hypo.
- Diabetics must remain sober enough to care for themselves (perform
injections on schedule, etc).
- Excess alcohol consumption can cause increased serum triglycerides.
Few difficulties arise if following points are observed.
Acceptable in moderation:
- Red wines.
- Dry or medium-dry white wines.
- Dry sherries.
- Dry light beers (lagers, light ales fermented with low residual
sugar).
- Spirits (whiskey, gin, vodka, etc) with "diet" mixers.
Use with extreme caution due to high sugar content:
- Sweet wines or sherries.
- Ports.
- Heavy or dark sweetened beers (stout, porters, etc which have
high residual sugar).
- Wine coolers.
- Spirits with normal mixers.
- Cocktails.
- Liqueurs.
Use with extreme caution due to very high alcohol concentration:
- Neat (undiluted) spirits.
General rules:
- Simple drinks (wine, beer) are more reliable than complex mixed
drinks, especially in company where you have less control over
the contents or concentration.
- Drink with or after food to avoid hypo problems.
- Approach anything with caution if you are in doubt.
- Low alcohol beers are not necessarily preferred - many of them are
rather sweet.
- Alcohol provides about 7 cal/g of food energy. Some is lost in the
urine, but most is converted by the liver into forms which can be
used for energy elsewhere in the body or stored as fat.
Clearly these succinct rules are simplified and there are exceptions to
them (for example, there are dry ports) but they are intended as a
general guide. I make no attempt to define the term moderation, this
will depend on the individual.
------------------------------
Subject: Necrobiosis lipoidica diabeticorum
Necrobiosis lipoidica diabeticorum (NLD) consists of oval plaques, usually on
the lower legs. It may start as small red spots or raised areas, which
develop a shiny, porcelain-like appearance. The plaques often turn a light
color due to extracellular fat (the "lipoidica"). They are often itchy or
painful. Typically the spots turn a brownish color, which fades slowly but
is permanent.
NLD is not related to any other complication of diabetes. In particular, NLD
does not presage eye, kidney or vascular problems.
NLD is much more common in diabetics, who account for perhaps 2/3 of all
cases. Many of the remainder develop diabetes, and NLD should be considered a
warning sign of diabetes. Reports vary widely on exactly who is most at risk.
About 1% of diabetics have some degree of NLD ... plus or minus 1%, depending
on which report you read. Some reports say NLD occurs more often in young
women, but some textbooks disagree.
The real dangers seem to be ulceration, infection, and the stress from the
appearance. Ulceration sometimes occurs spontaneously, and often as a result
of trauma.
Ulceration is often a result of scratching or trauma, and the ulceration from
scratching sometimes heals very slowly. Thus avoiding scratching and trauma
decreases the amount of ulceration, though some ulceration will occur anyway.
There are some images of NDL lesions at
http://tray.dermatology.uiowa.edu/DermImag.htm
No particularly good treatment seems to be known. Topical steroids (that is,
creams) are the most common first choice. The ulcerations usually heal if
cared for properly, and drastic measures are not called for in most cases.
William Biggs reports that skin grafts may be necessary in cases of severe
ulceration, but do not tend to give results that are cosmetically attractive.
Other treatments reported to help sometimes are oral aspirin, pentoxifylline,
dipyridamole, locally injected steroids, and systemic steroids. No one claims
to be able to predict what will work on any given patient, and often not much
of anything is effective. However, the ulcers usually heal if given
supportive treatment. Surgery should be avoided. Ineke van der Pol reports
finding relief in Chinese herbal treatments.
STEROID WARNING: locally injected and systemic steroids raise blood glucose
and cause severe problems regulating blood glucose. These should be used only
as a last resort. Topical steroids (creams and inhalers) cause no such
problems.
Note that treatment is not a medical necessity except for ulcerations and
infections. Otherwise, the purpose of treatment is to prevent ulcerations
and infections, decrease pain and itching, and improve the appearance.
NLD is the subject of occasional articles in scientific journals on diabetes
and on dermatology. Betsy Butler has researched the medical journals, finding
little beyond what I've reported above -- in her words, "no good answers".
_Therapy for Diabetes Mellitus and Related Disorders_, published by the ADA,
has a section on necrobiosis lipoidica diabeticorum and its treatment.
Ineke van der Pol has started a mailing list about NLD at
http://groups.yahoo.com/group/necrobiosis.
I thank the following people, especially Betsy, who posted the information
from which I derived this section:
Betsy Butler Polley (who says sorry, she doesn't have any information
besides what's here)
William Biggs <reddy_biggs(AT)msn.com>
Tari M. Birch <tm_birch(AT)pnl.gov>
Terence Griffin (who also says he doesn't have any other info)
Bill Barner <barner(AT)mail.loc.gov>
Ineke van der Pol <fluo(AT)chello.nl> (who has no further information
but is happy to correspond about NLD if you wish)
------------------------------
Subject: Has anybody heard of frozen shoulder (adhesive capsulitis)?
Short answers: adhesive capsulitis, aka frozen shoulder, is a painful
condition that limits motion in one shoulder or both. It's not found
exclusively in conjunction with diabetes, but occurs sufficiently more often
with diabetes to be considered a diabetic complication. Don't be surprised,
though, if your doctor isn't aware of this connection. Avoid surgery (which
seldom helps) and cortisone (which plays havoc with blood glucose control);
take physical therapy seriously; expect to take about two years to recover.
Lee Boylan <lboylan(AT)cisco.com> wrote:
There are three treatments usually offered for frozen shoulder: surgery,
cortisone shots and exercises. Surgery offers the best transfer of money to
a surgeon but the patient ends up needing to do exercises anyway.
Cortisone offers quick pain relief but not full shoulder relief, so the
patient is told to do exercises. Also, a DMer has drastically changed
insulin requirements after taking a cortisone injection.
Exercise, with alternating hot and cold packs and optional NSAIDs, offers
slow and sometimes painful therapy that gets full or nearly full
restoration of movement. Just don't let it discourage you, because
improvement comes slowly. Keep at it! Eventually, you will have pain-free
motion in your arm.
And I'll re-emphasize what Lee says: DON'T TAKE STEROIDS LIGHTLY. Including
cortisone. This warning should not be necessary, but unfortunately some
doctors are unaware of what steroids do to blood glucose. If your doctor
doesn't understand how serious a problem this is, insist on including an
endocrinologist in your medical team.
Lyle Hodgson <lyle(AT)world.std.com>, who has been through adhesive
capsulitis in both shoulders, wrote:
I suggest anybody who really wants to know about it who can visit Boston go
to see Dr. Gordon Lupien, who used to be an orthopedic surgeon at Joslin
and, according to a couple doctors I asked, knows more about adhesive
capsulitis in diabetics than anyone else, period.
Factoids:
o Diabetics get "frozen shoulder" more than non-diabetics.
o Women get "frozen shoulder" more than men.
o Everybody I talked to who had ever treated "frozen shoulder" said that
every patient they'd seen with it got over it in two years, no matter
whether they did the exercises or not.
o The exercises and ESPECIALLY PHYSICAL THERAPY help tremendously in
retaining what range of motion you still have and in keeping the pain
(which can be incredible) to a minimum.
o The exact cause and pathology is completely unknown, but often adhesive
capsulitis follows an untreated injury, or bursitis or tendonitis or even
a period of no stretching exercises.
o Adhesive capsulitis is often mis-diagnosed as a torn rotator cuff, which
may well be involved but which will heal without the surgery most
orthopedic surgeons prescribe for it. What's more, an often undiscussed
side-effect of the surgery is permanently reduced range of motion,
because tendons are snipped and resewn, and thus shortened.
o If the exact pathology is unknown, it is certain that it involves
scarification of the tissues in the shoulder "capsule", and from what I
understand scar tissue is at least partly caused by glycosulation of
tissues, so good control is (once again) the best prevention .
o Cortisone is often prescribed for non-diabetic patients, and only for
diabetic patients by doctors unfamiliar with the dramatic effect
cortisone has on bloodsugar levels. Dr. Lupien told me cortisone doesn't
even really have any long-term effect except to reduce the pain for
awhile, and should be avoided completely since it could also permanently
screw up how your body deals with cortisone.
o Recommended treatment: daily exercises, biweekly physical therapy, daily
(if possible) swimming, and acetaminephen (Tylenol). Extensive use of
non-steroidal anti-inflammatories is not recommended. These include
aspirin, ibuprofen (Advil/Motrin), and naproxen.
Here's a sort-of-a- self test for adhesive capsulitis:
1. Lay on the floor on your back. Can you raise your arm over your head in
a 180-degree arc and rest it on the floor without pain or *too* much
stretching?
2. Stand sideways next to a wall, and walk your fingers up the wall until
you can't reach any more. Can you almost press your armpit to the wall?
If either of these gives you significant trouble -- you can't quite reach
the floor behind your head, you can't touch the wall with your elbow, and
either or both gives you pain -- you may (MAY, MAYBE, MIGHT) have adhesive
capsulitis.
Two doctors and one physical therapist told me that shoulders tend not to
get the regular stretching that other joints get: a person can go for long
periods of time without moving the shoulder much out of its usual hanging
position, and then often the movement doesn't count for much. Hips are
stretched at least a little several or many times a day, even with
sedentary types who only sit, stand, sit, stand, walk a little, sit, etc.:
the tissues are still fairly regularly manipulated so that it is much
harder for them to freeze up.
Lyle, who is always interested to hear what else anyone has learned about
this little-studied, little-mentioned condition
------------------------------
Subject: Gastroparesis
J K Drummond (no longer on the net, but well) contributed this section.
Gastroparesis (gastroparesis diabeticorum if a diabetes complication) is
nerve damage caused delayed gastric emptying. This more common than
recognized irregular digestive slowdown interferes with blood glucose
regulation and oral medicine absorption.
Severity ranges from occasionally recurring bothersome symptoms like
nausea, vomiting, constipation and diarrhea to total "stomach paralysis"
-- the inability to consume/absorb any food. This worst stage requires
tube feedings as the sole source of nutrition, IVs for hydration, and
gastric suction for waste elimination. Be aware that "stomach trouble" may
be more serious for one with diabetes and report digestive problems to
your physician. Do not wait until you have had gastroparesis for several
years or end up in the emergency room because you cannot eat. If you
are a health professional, please routinely ask diabetics if they have
digestive problems.
Many with gastroparesis are undiagnosed or misdiagnosed and find little
information about it. Often they have been used as guinea pigs in
guessing games of hit or miss treatment trials. The scary quest has
only just begun to find answers, reason, and solutions to this lesser
known and mystifying complication of diabetes. There are people who
have found answers in their lonely struggle with gastroparesis.
Most folks with gastroparesis are female, with type 1 diabetes for 20-25
years and are age 25-45 at onset of gastroparesis.
These incomplete lists of symptoms, treatments, helpful & stressful
foods, and social aspects have been compiled mostly from patient reports.
There is no all-patient guarantee of experience. CHECK WITH YOUR DOCTOR!
S Y M P T O M S
Physical Psychological
nausea fatigue- muscle weakness
vomiting fear
constipation frustration
diarrhea stress
bloating
lack of hunger
indigestion
high stomach acidity
reflux
weight loss
inability to control blood sugars
DIAGNOSIS**
Symptoms together with gender &/or years of diabetes (clinical intuition)
Gastric Mobility Transit Test
Manometric Motility Study
Diabetics are also subject to all forms of non-diabetic gastropathy so be
aware that tests are necessary to eliminate and/or verify other diagnoses.
TREATMENTS
NUTRITION - MALNUTRITION Dietitians recommend 6 small meals daily
Foods more easily digested Foods increasing symptoms
fruit juices protein foods - meat, eggs
canned fruits & vegetables raw fruits & vegetables
soft starches (white bread dairy products
& rice, mashed potatoes,
cereals) caffeine, chocolate
soups nuts & seeds
baby foods
non-carbonated beverages
jello
Liquid Nutritional Supplement Drinks
Diabetic: Choice dm (Mead-Johnson), Glucerna (Ross Labs)
Ensure Glucerna OS (Ross Labs)
Non-diabetic: Ensure/Ensure plus, Sustacal (Ross Products Div)
Nutrition via:
IVs (fluids or TPN)
Tube feedings (eq. Osmolite or Supplena)
PHYSICAL - Remaining upright at least a half hour after eating,
stomach massage, enemas, glycerine suppositories, stool softeners
(for example, psyllium husk powder: Metamucil and other brands)
DRUGS - May have adverse side effects on other conditions. Ask your MD!
Reduce stomach acid: Zantac, Pepcid, Prilosec, Axid, Cytotec
Increase motility: Reglan (metoclopramide)
erythromycin
Propulsid (cisapride)
(in U.S. only under compassionate use protocol)
bethanechol
domperidone (U.S. availability: compassionate use only,
and for veterinary use -- it's used to treat
fescue toxicosis in horses)
Reduce digestive system spasm: dicyclomine
Diarrhea: immodium, clonidine
Nausea/vomiting: marinol, thorazine, ativan, inapsine, zephran, phenergan
Surgical (physical implants or alterations)
portacath or Hickman - IV hydration or Total Peritoneal Nutrition
jejunostomy - tube feedings
gastrostomy - for stomach suction (PEG tube)
gastric resectioning or stomach removal
gastric pacing - digestive pacemakers (experimental). Enterra Therapy by
Medtronic, gastric electrical stimulation (GES) neurostimulator implants
are approved as a humanitarian use device (HUD) since severe gastroparesis
(refractory to drugs) has less then 4,000 cases per year. More info at
http://www.medtronic.com/neuro/enterra/patient.html
insulin pumps
SOCIAL & PSYCHOLOGICAL ASPECTS
Frustration for patient and physician from the difficulty in balancing
insulin dosages and food intake to achieve level blood sugars with
unpredictable slowed digestion.
Additional psychological impact from delayed treatment due to relative
medical unrecognition causing underdiagnosis and even misdiagnosis (ex. as
anorexia nervosa if accompanied by vomiting).
Lack of ostomy education.
If/when eating ability returns following thinking that a normal diet could
never again be eaten it may cause physical & emotional anorexia.
Often felt burden to friends and family.
Most information was collected by the pioneering health professionals of
the defunct Gastroparesis Communication Network, updated by J K Drummond.
** If you have been or are out of work pursue Medicare/Medicaid & Social
Security Options IMMEDIATELY!
------------------------------
Subject: Extreme insulin resistance
Mayer Davidson writes several pages about insulin resistance in his
book _Diabetes Mellitus: Diagnosis and Treatment_. Except for what's in
[brackets], the following information is from pp 126-132 of the third
edition or pp 112-119 in the fourth edition. I'd recommend finding a
copy. Most university libraries will have it, even those without
medical schools. It's about $65; if necessary you can order from the
Rittenhouse Medical Bookstore in Philadelphia at 215-545-6072.
In this context, "insulin resistance" refers to patients requiring more
than the arbitrary amount of 200 units/day. Davidson uses the term
"insulin antagonism" for the phenomenon which is commonly part of type
2 diabetes.
Davidson cites ten major causes of insulin resistance. The first eight
are obvious major medical problems that you would immediately suspect
were related, so I won't bother listing those. Rarely, insulin is
destroyed at the subcutaneous injection site; this form can be treated
with normal amounts of insulin administered intravenously or
intraperitoneally.
The most common form of insulin resistance is immune-mediated. Everyone
taking injected insulin develops IgG antibodies to insulin. In most,
the antibody levels are low. In about 1 in 1000, the levels are much
higher, from 5 to over 1000 times higher than usual. In Davidson's
words:
The reason for this markedly enhanced response and the
subsequent decline to normal levels is completely unknown.
The antibodies bind to, and neutralize, the insulin.
At one time it was thought that the antibodies resulted from impurities
in the insulin preparations, and that using highly purified
preparations would avoid the problem. This has proven not to be the
case; purified insulin helps but usually does not resolve the problem,
[though it seems to be worth trying].
Also, switching to a different insulin does not help, as the antibodies
bind to beef, pork and human insulin. They may bind to one more than
the others, but the titers of antibody are so high as to neutralize
virtually all of any of the insulins.
Two treatments which are effective are not generally available in the
US.
First, insulin can be treated with sulfuric acid. The modified molecule
retains some biological activity but has reduced affinity for binding
to the IgG antibodies to insulin. This treatment was tested by a
Canadian laboratory in the late 1960s but is available in the US only
by special petition to the FDA. Novo Nordisk Pharmaceutical can provide
information at 609-987-5800.
Second, fish insulin works in humans but does not bind to the
antibodies. Cod insulin, for example, differs from human insulin in 33
amino acid positions compared with 3 differences for beef insulin. But
nonmammalian insulins are not available in the US at all.
This leaves the two treatments that are actually used on a regular
basis, and a promising new treatment.
Because this condition is rare, there's been little experience treating
it with lispro insulin (Humalog). That experience is promising; it
appears that the structural change in lispro may inhibit the antibody
binding. If this is borne out by further experience, lispro will be the
treatment of choice for extreme insulin resistance.
Glucorticoids such as prednisone decrease the extreme insulin
resistance, possibly by inhibiting the production of IgG antibodies. As
the antibodies have a half life of 3-4 weeks, the response is delayed,
during which time bg control is even more difficult due to the effects
of the glucocorticoids. After several weeks the dosage can be reduced
to maintenance levels or eliminated, but relapse is common. Since
glucocorticoids have other nasty effects in addition to the problems
listed above, there are significant problems with this course of
treatment.
Davidson's recommendation is based on The Good News: insulin resistance
is self-limited and only lasts a few months to a year. He simply uses
as much insulin as is needed in the meantime. U-500 concentration is
available for this purpose. The antibodies delay the action, so even
though U-500 is regular insulin it acts like a lente or semilente in
resistant patients. For unknown reasons, much less U-500 is needed than
the equivalent amount of U-100, 50% to 75% less. Since the situation is
difficult to manage and is temporary, Davidson advises not trying for
good bg control, but just avoiding ketosis and the overt symptoms of
hyperglycemia (thirst, excess urination, infections).
When insulin sensitivity returns, it can happen quite suddenly.
Davidson starts reducing the high insulin doses when fasting bg is
under 200 mg/dl (11.0 mmol/L). At these times, large amounts of insulin
previously bound to the antibodies may be released, so avoiding
hypoglycemia is a major concern. The return to normal sensitivity will
take at least several weeks due to the half-life of the antibodies, and
insulin requirements may fluctuate a great deal during this time. A
fast response to U-500 insulin (2-4 hours from injection to measurably
lower bg) may indicate the decline of insulin resistance.
[This was the movie. Now go read the book.]
------------------------------
Subject: What is pycnogenol? Where and how is it sold?
All sections on pycnogenol are written by Laura Clift <LauraRuss(AT)aol.com>.
Numbers in parentheses refer to the section on "Pycnogenol references".
Pycnogenol, a.k.a. Revenol, is a substance that has been mentioned in
misc.health.diabetes as an aid/cure for several diabetic complications.
Pycnogenol is a bioflavanoid, also identified as an oligomeric
proanthocyanidin (OPC) and a procyanidin, which is found in the bark of
conifers, specifically the maritime pine (_Pinus maritima_) and the Canadian
spruce (_Tsuga canadensis_) and in grape seeds. The substance was patented in
the US (patent 4,698,360) in 1985 by J. Masquelier of France.
Pycnogenol is sold on several web sites in addition to health food stores. The
web sites are set up in a pyramid scheme with the claims of quick riches for
new distributors. Most of the sales pitches rely on first-person
"testimonials". Some pitches include a list of published scientific studies
that, according to the pitch, support the claims of the ad. In the following
sections I examine the sales claims, investigate the ad's publication list,
and establish a bottom line.
------------------------------
Subject: What claims do the sales pitches make for pycnogenol?
Written by Laura Clift.
Pycnogenol or Revenol (super-enriched pycnogenol) claim to be the world's
most powerful anti-oxidant (vitamin C and E are anti-oxidants). The ads state
pycnogenol is non-toxic, non-mutagenic, has high bioavailability, crosses the
blood-brain barrier, enables vitamin C to remain in the body for 3 days as
opposed to 3 hours, increases capillary resistance, decreases capillary
fragility and permeability, decreases lower leg volume, strengthens collagen,
and remains active in the body for 72 hours.
Ads make claims that pycnogenol prevents, aids and/or cures the following
conditions:
arthritis, cancer, AIDs, stomach pains, aches and pains, aging, abnormal
menstrual bleeding, asthma, atherosclerosis, bruises, diabetic
retinopathies, dry skin, edemas, excessive blood sugar, fatigue, hay fever,
heart attacks due to vascular accidents, hemorrhoids, inflamed tissue,
internal bleeding, jet lag, kidney disease, menstrual cramps, phlebitis,
poor circulation, skin elasticity, strokes due to cerebral accidents,
stress, ulcers, varicose veins, multiple sclerosis, prostate problems,
sleep disorders, dog and horse cancers, attention deficit disorders, and
increased physical endurance.
------------------------------
Subject: What's the real published scientific knowledge about pycnogenol?
Written by Laura Clift. (refs) point to "pycnogenol references" section.
In a study examining the anti-oxidant action of several bioflavanoids,
(-)-epicatechin 3-O-gallate and (-)-epigallocatechin 3-O-gallate were both
more potent than pycnogenol against the free radicals DPPH, superoxide anion,
OH, and OOH, although not by much (1).
The toxicity of pycnogenol is not established in published reports.
Proanthocyanidin mutagenicity is tricky, if it is completely pure it is
considered non-mutagenic. However, there is an impurity that is very similar
and hard to remove in the purification of proanthocyanidin that is mutagenic
(2).
No published work could be found on the bioavailability of pycnogenol in
particular, but oral ingestion of bioflavanoids in general results in a low
bioavailability (3).
Pycnogenol does cross the blood-brain barrier in rats when given as an
intraperitoneal injection (4). The same study seems to indicate that
pycnogenol can increase capillary resistance and decrease capillary
permeability in rats. A clinical study on 25 patients indicated an increase
in capillary resistance (5). When administered by intraperitoneal injection
to rats, chemically induced edema of the paw was decreased (6).
There are no published studies on pycnogenol's interaction with vitamin C and
most of the preventions, aids and/or cures claimed. However, procyanidol
oligomers offered no protection for venous disease from hypoxia (lack of
oxygen) (7).
------------------------------
Subject: How reliable is the literature cited by the pycnogenol ads?
Written by Laura Clift.
Masquelier J, Michaud J, Laparra J, Dumon MC. Flavanoids et pycnogenols. Int
J Vit Nutr Res 1979;49(3):307-11.
Article in French. Abstract states that the article describes pycnogenol
chemically designating the compound as "pycnogenol" to distinguish it from
the hundreds of other bioflavanoinds.
Uchida S, Edamastu R, Hiramatsu M, et al. Condensed tannins scavenge active
oxygen free radicals. Med Sci Res 1987;15:831-2.
Pycnogenol is a free radical scavenger (anti-oxidant) in vitro (outside of
a living animal, or, in a petri plate).
Lagrue G, Oliver-Martin F, Grillot A. Etude des effects des oliomeres du
procyanidol sur la resistance capillaire dans l'hypertension arterielle et
certains nephropathies. La semaine des Hopitaux de Paris 1981; 57:1399-1401.
French article. Abstract states capillary resistance increased in 25
patients. No dose amount or route of administration in the abstract.
Cahn J, Borzeix MG. Etude de l'administration des oligomeres du
procyanidoliques chez le rat: Effets observes sur les alterations de la
permeabilite de la barrier hematoencephalique. La semaine des Hopitaux de
Paris 1983;59:2031-4.
French article. Abstract states that pycnogenol crosses the blood-brain
barrier in the rat and affects capillary permeability. Route and dose not
presented in abstract.
Tixier JM, Godeau G, Rober AM, Hornebeck W. Evidence by in vivo and in vitro
studies that binding of pycnogenols to elastin affects its rate of
degradation by elastases. Biochem Pharmacol 1984;33(24):3933-9.
Study with (+) catechin and pycnogenol (states they are related substances,
but act differently, including the results of this study). Pycnogenol
prevents the break down of elastin in vitro and in rabbits.
Kuttan R, Donnelly PV, DiFerrainte N. Collagen treated with (+)-catechin
becomes resistant to the action of mammalian aollagenase. Experentia
1981;37:221-3.
(+) catechin is not pycnogenol (see above). Study does not investigate
pycnogenol.
Reimann HJ, Lorenz W, Fischer M, et al. Histamine and acute hemorrhagic
lesions in rat gastric mucosa: prevention of stress ulcer formation by
(+)-catechin, an inhibitor of specific histidine decarboxylase in vitro.
Agents and Actions 1977;71:69-72.
(+) catechin is not pycnogenol (see above). Study does not investigate
pycnogenol.
Markle RA, Hollis TM. Rabbit aortic endothelial and medical histamine
synthesis following short-term cholesterol feeding. Exp Mol Pathol
1975;23:117-23.
Markle RA, Hollis TM. Variations in rabbit aortic endothelial and medical
histamine synthesis in pre- and early experimental atherosclerosis. Proc Soc
Exp Biol Med 1977;155:365-8.
Hollis TM, Furniss JV. Relationship between aortic histamine formation and
aortic albumin permeability in atherogenesis. Proc Soc Exp Biol Med
1980;165:271-4.
Does not study pycnogenol or any bioflavanoid. Logic may go like this:
pycnogenol is similar to (+) catechin which can effect histamines. Here are
some cardiac/circulatory problems that are affected by histamine.
Therefore, pycnogenol will prevent these diseases. Logic may be OK for a
hypothesis but is flawed as a conclusion, especially since (+) catechin and
pycnogenol act differently in most studies (see above).
Feine-Haake G. A new therapy for venous diseases with
3,3,4,4,5,7-hexa-dihydro-flauan. Z Allgemeinmed 1975;51(18):839.
German article, no abstract translation; chemical name implies (+)-catechin
was studied.
Blazso G, Gabor M. Oedema-inhibiting effect of procyanidin. Acta Physiol Acad
Sci Hung 1980;56(2):235-40.
Chemically induced edema of a rat's paw was decreased with intraperitoneal
injections of pycnogenol.
------------------------------
Subject: What's the bottom line on pycnogenol?
Written by Laura Clift. (refs) point to "pycnogenol references" section.
All bioflavanoids are anti-oxidants (1,8,9) and may effect capillary
hyperpermeability (8,9), inflammations (3,8), and edemas (8). However, there
is no bioflavanoid deficiency condition, and they have "no accepted
preventive or therapeutic role in vascular purpura, hypertension,
degenerative vascular disease, rheumatic fever, arthritis, cancer, or any
other condition" (9). This was as of 1988; no mention of bioflavanoids is
made in the 1994 edition of this reference. Most pycnogenol studies and/or
claims come from the early 70's to mid 80's. Promising starts are never
followed up on. Most later studies seem negative (both pycnogenol and
bioflavanoids), especially about the oral route. With all but one study
performed in rodents, there is a very definite lack of information on how
this substance acts in humans and what possible side-effects it produces.
The sales pitch seems to be taken from the 1985 patent. Filing a medical
patent doesn't mean the substance is thoroughly studied and its applications
are determined. A patent is filed when preliminary studies look promising and
you try to come up with every possibly use for the compound, no matter how
far out in left field it may be. If you do not hold the patent for the
application, someone else could conceivably use your compound for that
application and owe you nothing or a very reduced royalty.
In short, patent claims have no medical significance.
------------------------------
Subject: Pycnogenol references
Written by Laura Clift. This is the section to which the (refs) point.
1. Uchida S, Edamastu R, Hiramatsu M, et al. Condensed tannins scavenge active
oxygen free radicals. Med Sci Res 1987;15:831-2.
2.Yu CL, Swaminathan B. Mutagenicity of proanthocyanidins. Food Chem Toxicol
1987;25(2):135-9.
3. Namgoong SY, Son KH, Chang HW, Kang SS, Kim HP. Effects of naturally
ocurring flavanoids on mitogen-induced lymphocyte proliferation and mixed
lymphocyte culture. Life Sci 1994;54(5):313-20.
4. Cahn J, Borzeix MG. Etude de l'administration des oligomeres du
procyanidoliques chez le rat: Effets observes sur les alterations de la
permeabilite de la barrier hematoencephalique. La semaine des Hopitaux de
Paris 1983;59:2031-4.
5. Lagrue G, Oliver-Martin F, Grillot A. Etude des effects des oliomeres du
procyanidol sur la resistance capillaire dans l'hypertension arterielle et
certains nephropathies. Las semaine des Hopitaux de Paris 1981; 57:1399-1401.
6. Blazso G, Gabor M. Oedema-inhibiting effect of procyanidin. Acta Physiol
Acad Sci Hung 1980;56(2):235-40.
7. Michiels C, Arnould T, Houbion A, Remacle J. A comparative study of the
protective effect of different phlebotonic agents on endothelial cells in
hypoxia. Phlebologie 1991;44(3):779-86.
8. Lonchampt M, Guardiola B, Sicot N et al. Protective effect of a purified
flavanoid fraction against reactive oxygen radicals. in vivo and in vitro
study. Arzneimittelforschung 1989;39(8):882-5.
9. Shils ME. Modern nutrition in health and disease. Philadelphia: Lea and
Febiger, 1988. p472.