2009 Fall Vol 30

Volume 30, Third Quarter 2009

Of all the different aspects of diabetescare that we need to improve, re-definingthe diabetes doctor visit has the potentialto allow those precious few minutes in theexam room to make a significant impacton clinical care and overall satisfaction for people with diabetes (PWD) andhealthcare providers.

In medical school, we are taught the art and science of performing a history and physical (H&P) exam. The format is fairly rigid, methodically marching

through a series of questions andmaneuvers in chronological order. It starts off with the history of present illness(HPI), which is a summary of the patient’smain problems, going through each one interms of what has changed since the lastvisit and the current status. Next is thepast medical history (PMH), whichrequires a listing of all current and pastmedical and surgical conditions includingmedications, allergies, smoking anddrinking habits, social situation and much

Dr. Edelman’s Corner

(Doctor Visit, continued on page 2 )

W hen it comes to diabetes care in this country, healthcare reformis urgently needed to more effectively and efficiently prevent,

diagnose and successfully treat this increasingly common chroniccondition. Careful evaluation of what works and what doesn’t workwill be needed to properly address the burden of diabetes thatcurrently affects the lives of 23 million Americans, in addition toanother 50-60 million individuals with “pre” diabetes.

inTHISissue

Dr. Edelman’s Corner

Is It Murder? Part 2

Question of the Month

Taking Control ofHypoglycemia

Kim Lyons, CelebrityFitness Trainer

Let Your Energy Lift You

Diabetes DiscourseHosted by Dr. Edelman

REDEFINING THEDIABETES DOCTOR VISITREDEFINING THEDIABETES DOCTOR VISIT

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more. Then there is the review ofsystems (ROS) in which questions areasked about every organ system in thebody from head to toe. You may be askedif you have been having any headaches,chest pain, shortness of breath, skinrashes, stomach problems, etc. All ofthis is followed by a detailed physicalexam (PE) which, if completed in athorough manner, can take quite sometime. The laboratory results are reviewednext and then there is the grand finale,the assessment and plan (A&P) for eachindividual problem. This last section is a mini-summary of the entire H&P andincludes all of the medication adjust-ments to be made as well as tests andconsults that will be needed eitherimmediately or before the next visit. Oh yeah…don’t forget that new pre-scriptions and refills may be needed. I hope you are beginning to see thepicture I am painting for you. All of this in a typical doctor visit?

When it comes to dealing with aperson living with diabetes, our formalevaluation process is quite ineffective,inefficient and cumbersome, wasting alot of precious time. Part of the problemis that most health care professionalsspend less than 2% of their traininglearning about diabetes managementand do not know what questions to ask or how to ask them. In addition,insurance companies may not pay theprovider for services unless there is documentation in the chart that all ofthe perfunctory items in a typical H&Phave been addressed and completed,even if they do not pertain to the mostcrucial aspects of diabetes care! Lastly,the time allotted for an appointment is

too short and should be adjusted upwardfor a diabetes appointment.

We need to individualize the diabetesvisit and prioritize the most importantissues in order to address the emotional,physical and medical barriers limitingsuccessful diabetes management. Ibelieve the patient’s questions andconcerns should be addressed first andnot left to the last few seconds as thedoctor hurries off to the next examroom. Listening, instead of asking aseries of standard non-diabetes relatedquestions, is the best way to start anevaluation. The bulk of the availabletime needs to be spent on what islimiting the PWD from achieving an A1c value below 7%, includingreviewing home or continuous glucosemonitoring results, addressing dietarystruggles and any difficulty maintaininga regular exercise program, as well asachieving appropriate blood pressureand cholesterol levels. I want mypatients to walk me through a typicalday in their lives in order to get a graspof what could be the main limitingfactors in getting to goal. The sensitiveissues of depression, erectile dysfunctionand other psychosocial problems must bediscussed openly and as often as needed.If appropriate, the significant other, or“type 3”, should be there to listen, learnand ask questions that relate to theirloved one living with diabetes. Diabetescannot be treated in a vacuum because

Steven Edelman, MDFounder and DirectorTaking Control Of Your Diabetes

Doctor Visit (continued from page 1)

2 MyTCOYD Newsletter, Vol. 30

SpecialAcknowledgements

MyTCOYD Newsletter is offered as a paidsubscription of Taking Control of YourDiabetes. All material is reviewed by amedical advisory board. The informationoffered is not intended to constitutemedical advice or function as a substitutefor the services of a personal physician. Onthe contrary, in all matters involving yourhealth, TCOYD urges you to consult yourcaregiver. ©2009 All rights reserved.

(Doctor Visit, continued on page 12 )

Medical Advisory BoardChair: Ingrid Kruse, DPMVeterans Affairs Medical Center

Alain Baron, MDCEO, Ethos Pharmaceuticals

John Buse, MD, PhDUniversity of North Carolina

Jaime Davidson, MDDallas, TX

Mayer Davidson, MDDrew University

Daniel Einhorn, MDDiabetes & Endocrine Associates

Robert Henry, MDVeterans Affairs Medical Center

Irl Hirsch, MDUniversity of Washington

Board of DirectorsSteven V. Edelman, MDFounder and Director, TCOYD

Sandra BourdetteCo-Founder and Executive Director, TCOYD

S. Wayne KayCEO, Response Biomedical Corp.

Margery Perry

Terrance H. GreggPresident & CEO, DexCom, Inc.

Daniel SpinazzolaPresident, DRS International

Contributing AuthorsSteven. V. Edelman, MDRiva GreenburgKriss Halpern, JDMichele D. HuieChristine LuuCandis Morello, PharmD, CDE

TCOYD TeamSteven V. Edelman, MDFounder and Director

Sandra BourdetteCo-Founder and Executive Director

Jill YapoInformation Manager

Michelle DayMeeting Planner

Antonio HuertaHealth Fair Manager

Michele HuieCommunications and Outreach Manager

Alice HoweCME Manager

Julia LafranchiseProgram Support

MyTCOYD NewsletterMichele Huie, Editor in Chief

Design: Hamilton Blake Associates

Taking Control of Your Diabetes 3

In the first hypothetical raisedpreviously [none of these hypotheti-cals are based on an actual incident],the driver accidentally took a shot offast acting insulin instead of the slowacting he uses as basal coverage; hewent for a long drive; he suffered asevere reaction; he got into a caraccident; someone was killed.

In this case, the driver did notknowingly do anything wrong. Thesevere hypoglycemic event was theresult of a mistake. There was nointentional act. There was no plan to harm anyone. Thus, it appearsobvious that murder could notreasonably be considered. But reasondoes not always control events whensomeone is killed. Police andprosecutors can be under extraordi-nary pressure when an innocentperson dies. Loved ones want anddeserve an answer: something toexplain their terrifying loss; somedespicable criminal to blame. Whenquestions are asked and answersdemanded, things are often not so black and white.

If a murder charge is not

appropriate because there was nointentional effort to kill, some lessercharge would have to be considered.In California, there are two types ofvehicular manslaughter. The first isfelony manslaughter which requiresrecklessness. The second is amisdemeanor which requiresnegligence. Both alsorequire an unlawfultraffic event. Theerratic driving thatpreceded the accidentmay qualify. In Black’sLaw Dictionary reck-lessness is defined as,

“the creation of a substantial andunjustifiable risk of harm to others and by a conscious (and sometimesdeliberate) disregard for or indiffer-ence to that risk; heedless; rash.Reckless conduct is much more than mere negligence; it is a gross deviation from what a reasonableperson would do.”

Negligence is defined as,“the failure to exercise the standard

of care that a reasonably prudentperson would have exercised in a

similar situation…”A driver with diabetes who acci-

dentally takes the wrong insulin hasnot had a “conscious disregard” foranything. He was not conscious ofthe error so recklessness does notappear to be an appropriate charge.Such a driver also might not bedeemed negligent since a reasonablyprudent person with diabetes takinginsulin might very well have done the same thing. There is anargument, however, that a personwho accidentally takes the wronginsulin was legally negligent since

most people whotake these insulinsdo so every daywithout makingthis particularerror. At the

moment of the mistake, it seemsobvious that the driver was notreckless and at least arguable that he was not even negligent. Thisdriver did nothing at all that he knew was wrong at the time and itdoes not appear that he did anythingespecially willful in making the error.

However, if the driver recognizedhis mistake at the time, how did heallow himself to drive afterwards? For his own safety he would have totreat the low immediately; glucagonor cans of juice and glasses of milk or food with high carbs would be

By Kriss Halpern, JDBy Kriss Halpern, JD

(Is It Murder?, continued on page 4 )

I n the last issue we described three hypothetical incidentswhere a car accident caused by a driver suffering severe

hypoglycemia resulted in a death. We left for this issue thequestion of whether any of the drivers might properly becharged with murder.

A driver with diabeteswho accidentally takes thewrong insulin has not hada “conscious disregard”

for anything.[ ]


needed; an urgent call to a physicianmight be needed as well. If the driverignored these obvious needs and wentdriving instead, this might well be acase of criminal recklessness. Is therea defense to such an act? Of course,but one would need to know muchmore. Was the driver suffering fromsome mental incapacity as a result ofthe mistake? Did he comprehendwhat he had done? Did he decide todrive to a hospital and end up in anaccident along the way? These aresome of the questions that need to beconsidered before you can assesswhether there wascriminal responsibil-ity, because each ofthem go to the question of knowledgeand intent relating to the event.

I have met with prosecutors whoargue that a person who knowinglytakes insulin and begins drivingshould be treated no differently thana drunk driver if someone is killed.But a mistake in insulin dosage alone is not a criminal act. Let’s breakit down. First, a person who drinks alcohol

does not need to drink in order tosurvive. Taking insulin in order tosurvive and drinking alcohol are not the same because the reason for using them is utterly different. Second, drinking alcohol in certain

amounts is always dangerous whendriving. Taking insulin by a person for whom it has been prescribed isnot. There is a clear differencebetween drinking five bottles of beer and taking five units of insulin.Both can be dangerous, but only thealcohol is always dangerous whendriving. Safely adjusting insulin

dosages is not automatic and mistakesare made by all of us. Drinkingcertain amounts of alcohol is alwaysand inevitably dangerous. Takingcertain amounts of insulin might bedangerous one moment and perfectlyproper at another.

Third, because insulin is neededfor survival and because it is notalways obvious when it might betaken excessively, the idea thatsomeone recklessly or knowingly took it to excess is far more difficultto determine. It would be a rare and odd case when someone

knowingly andintentionally tookinsulin to excess.

The same is not true for alcohol.Insulin is taken for the purpose ofconverting carbohydrates to energy; it is not taken for pleasure or enter-tainment; it is not taken by a personwith diabetes purely for theexperience of doing so. When it istaken to excess it is virtually alwaysan unintended mistake. Fourth, when a person drives after

overdosing insulin there is still anopportunity to avoid harm—either by testing and avoiding a severe low,or by pulling over when one feelssymptoms and treating the low beforedriving again. Most of us who takeinsulin have reason to believe we can avoid danger while driving. As a result, we have a legitimate basis to argue that we did not do anythingcriminal if we make a mistake andtragedy occurs. In our experience, we know when we are low and havean opportunity to avoid a seriousproblem before it becomes a danger. Ifan incident occurs it is an aberration.

Fifth, at the moment of severehypoglycemia we are not in control of our thoughts and actions. We have no mental capacity to take an intended action. Severe hypo-glycemia can sometimes occur inwhat seems like a virtual flash. Aperson in this diminished capacitycannot be guilty of a criminal act thatrequires intent. This is particularly sowhere that person did nothing inten-tionally to put him or herself into astate of diminished capacity. The goalwas not the feeling that accompaniesdiminished capacity as it is withsomeone who drinks to excess. Thegoal was proper blood glucosemanagement.

These are reasons to distinguishtaking insulin from drinking alcohol.They are also reasons that make ahypoglycemic event that leads to anaccident that results in death notcriminal in nature. Not murder andnot manslaughter. A horrid accident.But not criminal. Not something thatmerits time in jail.

Another hypothetical described inthe last TCOYD newsletter is about a serious low blood sugar in whichthe driver does not recognize hersymptoms until it is too late and isunable to pull over safely and treatthe low before an accident occurs. I have represented about one hundredpeople in license suspension hearingsover the past ten years, half of whomwere involved in an event of thisnature. In nearly all cases, no one was injured. But that is fortuitous.When we go severely low our bodiesand minds slow down; we cannotreact normally. If we do not pull overbefore the low becomes severe, an

Is It Murder? (continued from page 3)

A mistake in insulin dosagealone is not a criminal act.[ ]

nswer: The first measurable laboratory abnormality in the course of diabetes related kidney disease is thepresence of small amounts of albumin in the urine, which is referred to as microalbuminuria. Albumin is a proteinthat is normally not found at all, or only in very small amounts, in the urine. The prefix micro refers to theamount (small) of albumin in the urine. People with persistent microalbumin in the urine have a higherlikelihood of experiencing decreasing kidney function if it is left untreated over a period of years.

Remember that there are no symptoms of kidney disease in the early stages, which is why this yearly screeningtest is so important. If you have type 1 diabetes, you should be screened for microalbuminuria once a yearbeginning 5 years from the time of your diagnosis. People with type 2 diabetes should be screened every year fromthe time of diagnosis. Certain situations, such as strenuous pounding exercise, like running, may make yourmicroalbumin test positive even though you do not have diabetic kidney disease. Hence, confirming the presenceof microalbuminuria with at least one or two additional tests is important after a few days without heavy-dutyexercise. If it remains positive, strict glucose and blood pressure control, and the use of certain medications suchas ACE inhibitors, will be the mainstays of therapy. If you do have persistent microalbuminuria, it is mostimportant to treat it aggressively.

Question of the Month

ABy Steven Edelman, MD

Question: I am 26 years old and have been living withdiabetes for 6 years. My doctor recently told me the

microalbumin level in my urine is high. Can you please tellme about the microalbumin test and what it means?

accident is possible at any moment.When that happens, and someone iskilled, a criminal charge willinevitably be considered.

The reasons for the severe lowblood sugar, and the actions of thedriver prior to the accident, need tobe considered with a clear under-standing of the medical implicationsof her actions, and her state of mindat the time, to come to a reasonabledetermination of the degree of faultinvolved and whether her actionscould reasonably be consideredcriminal in some form.

No intentional act of murder took place. The driver did not intendto kill someone. Therefore, murdershould not be charged.

This does not mean such an event can never be criminal. Butmore needs to be known about thedegree of intent and responsibilitybefore a criminal charge is made.

The third hypothetical presentedin the prior issue suggests when acriminal charge might be properlymade. In that example, the driver has had many incidents of severehypoglycemia. The driver clearly hashypoglycemic unawareness—in otherwords, he does not recognize hypo-glycemia in time to avoid it becausehe does not feel symptoms of theseevents when they happen. He hashad prior events where it happenedthat were severe and dangerous. He has been warned about it by his

physician. He does a number ofthings that set up a severe anddangerous event on this occasion: he takes part in exercise, knowingthat this will lower his blood sugar;he then fails to test before driving,despite knowing he does notnormally feel symptoms of low blood sugar; he then drives asignificant distance without eating.

Does this make him guilty ofmurder if a tragedy occurs? No. Hedid not intend the tragic result. Washe reckless and guilty of manslaugh-ter? Perhaps. There are enough badfacts here that a prosecutor wouldobviously have to consider criminalcharges (assuming these facts become

(Is It Murder?, continued on page 11 )


Take Control ofHypoglycemia: How toPrevent and Treat Low Blood Glucose

H ave you ever felt irritable,confused, sweaty, weak, or overly

tired? You may have been experiencingsymptoms of mild to moderate hypo-glycemia, or low blood glucose. Manypeople are unaware of symptoms andexperience hypoglycemia without evenrealizing it. However, unawareness ofsymptoms can be extremely dangerous.Untreated mild to moderate hypo-glycemia may lead to severe lows inblood glucose, unconsciousness,diabetic coma, and, in rare situations,death. The good news is that you canbe prepared. Education is key—byarming yourself with tools to preventand treat hypoglycemia, you can takecontrol.

What is Hypoglycemia?Normal blood glucose concentra-

tions, even during fasting, are usuallygreater than 70 mg/dL.

Low blood glucose can be caused byskipping meals, leaving too much timebetween meals, not eating enough, over or incorrect medication use(especially with insulin), vomiting,diarrhea, vigorous exercise, andexcessive alcohol intake. Hypoglycemiacan occur at any time, day or night. Byregularly monitoring blood glucose,eating nutritious meals, taking thecorrect doses of medications, and most

importantly, by being aware of thesymptoms, hypoglycemic episodes can be minimized.

How Do You Know if You Are Too Low?

Symptoms of mild to moderate hypoglycemia may include hunger, irritability, confusion, sweating, palpitations, tiredness, weakness,increased heart rate, nausea, tremors orshakiness, and anxiety. Since catchinghypoglycemia early is important, beingaware of symptoms is crucial. If ever indoubt about whether or not you are toolow, test your blood glucose to confirmhypoglycemia. If you experience hypo-glycemic unawareness, testing yourblood glucose at regular intervals, and especially before driving is veryimportant.

How Do You Treat Mild toModerate Hypoglycemia?

Treating hypoglycemia meansrestoring the glucose in your blood. You can raise glucose to treat mild tomoderate hypoglycemia with anapproach called the “Rule of 15.” 1. Test to determine blood glucose is

below 70 mg/dL. 2. Eat 15 grams of simple, concentrated

carbohydrates (for fast-actingsources, refer to the Table on thenext page).

3. Wait 15 minutes.4. Check blood glucose again.5. If blood glucose is still below


Candis M. Morello, Pharm D, CDE,FCSHP, Associate Professor ofClinical Pharmacy at UCSD SkaggsSchool of Pharmacy andPharmaceutical Sciences, ClinicalPharmacist at VASDHS

Christine Luu, First Year StudentPharmacist at UCSD Skaggs Schoolof Pharmacy and PharmaceuticalSciences.

LOWFEELING

Hypoglycemia can occur atany time, day or night.[ ]


70 mg/dL, consume an additional 15 grams of carbohydrates.

6. Follow up with a light snack (or with a meal if it is mealtime).

Mild to moderate hypoglycemiacan usually be reversed rapidly,within 5-10 minutes. Using the“Rule of 15,” blood glucose concen-trations increase quickly and youcan avoid over-treating byovereating, which could lead toelevated glucose concentrations and an undesired blood glucoseroller coaster. The table below lists15-gram amounts of effective fastacting carbohydrates includingglucose tablets, milk, fruit juice,regular soda, sugar, raisins, hardcandies, and glucose gels. Avoidfoods that are high in fat, such aspizza, candy bars, or doughnuts,because fatty foods slow theabsorption of carbohydrates, makingthe blood sugar rise take longer.However, if the only sugary food you have nearby is a candy bar or a doughnut, it is much better thannothing at all. If you experience

a ‘low’ right before mealtime, goahead and eat your meal withoutapplying the “Rule of 15” as long as the meal you are eating hassufficient carbohydrate to get yourblood glucose back up. Contact yourhealthcare provider if you frequentlyexperience low blood glucose as yourmedication may need adjusting.

How Do You Treat SevereHypoglycemia?

Untreated mild to moderatehypoglycemia can lead to severehypoglycemia and unconsciousness,a situation that cannot be self-treated. It is important to rememberthat the person experiencing severehypoglycemia cannot swallow.Force-feeding food or liquid to an unconscious person can lead to choking. Treatment of severehypoglycemia requires a glucagonemergency kit, which is availableonly by prescription. Glucagon is anatural hormone that works quicklyto increase blood glucose concentra-tions. The glucagon mixing andadministration instructions may

be confusing during an emergency. To prevent confusion in a stressfulsituation, it is vital to educatepeople around you (close friends,family, teachers, caregivers) how to prepare and administer glucagonbefore an actual emergency arises.Annual reeducation is recom-mended. Remember to checkexpiration dates regularly since you do not want to be caught in an emergency with an expired kit.Although some people go yearswithout needing to use theirglucagon emergency kits, it is veryimportant for all patients on insulintherapy to have these kits availableand to keep them easily accessible.Store them in several places such asin the bedroom, a purse, briefcase orbackpack, and let the people aroundyou know where the kits are located.

Bottom Line: Prevent and Prepare

To take control of hypoglycemiaand avoid severe episodes, pre-vention and being prepared areessential. Be aware of early warningsymptoms of hypoglycemia andrecognize when you are more likelyto go low. Keep fast-acting sources ofcarbohydrates such as glucose tabletsor hard candies in the car or withyou when traveling. Mini 4-ouncejuice boxes are the perfect size andcontain 15 grams of carbohydrates—keep some by the bed as a quicksource of glucose at bedtime or in

(Feeling Low, continued on page 9 )

SourceGlucose tabletsGlucose gelFruit snacksRaisinsNon-diet soft drinkFruit juice (apple/orange)Milk (non/low fat)

Quantity3-4 pieces (4 grams per piece)1 tube of 15 grams carbohydrates1 package1 ounce4 ounces (1/2 cup)4 ounces (1/2 cup)8 ounces (1 cup)

Fast-Acting Sources of Carbohydrates


T COYD had the chance to chatwith Kim Lyons, the face of the

new campaign Take the Next Step.

Kim, what is the Take the NextStep campaign?

Take the Next Step is an awarenesscampaign to educate people on howto get active, especially as it relates to nerve pain. The campaign isdesigned to help people with diabetesrecognize the symptoms of painfuldiabetic peripheral neuropathy(pDPN) and proactively talk to their doctors about incorporating thetreatment of pDPN into their overalldiabetes care. My involvementincludes participating at the TakingControl of Your Diabetes conferencesin order to encourage people to payattention to pDPN symptoms and get active.

Why did you get involved withthis campaign?

Sadly, there is a lot of disconnectbetween doctors and personal trainerswhen in fact they should be workingtogether on patient issues like obesityand diabetic nerve pain. When I wasapproached with the opportunity tobe a spokesperson for Take the NextStep it seemed like a terrific ideabecause I can really impact peoplepositively. I’ve seen so many benefitsthat occur when people become

active. There are many peoplewho think that they simplycan’t exercise, because theyare too big or are in too muchpain, but I encourage peopleto start small, just by taking a walk around the block ordoing some chair exercises in front of the TV. People arerelieved to learn what theycan do.

Do you train a lot of peoplewho have diabetes/sufferfrom pDPN?

Prior to working on TheBiggest Loser, I trained profes-sional athletes and movie starsso they looked good on the bigscreen. When I first started onThe Biggest Loser, I was outside of my comfort zone. I had to learn allthe things that come with beingobese: the stress on your heart, type 2diabetes, pre-diabetes, neuropathy. It was overwhelming, but at the same time, so much more rewardingthan getting someone ready for herwedding. I was giving someone a new chance on life, and I was totallyhooked on the reward.

Does exercise helpwith pDPN?

YES! Stayingactive is an

Kim Lyons, celebrity fitnesstrainer of The Biggest Losergets people moving at TCOYD

By Michele D. Huie


important part of any diabetes careprogram. This is especially true if youhave a complication like diabeticnerve pain. It may be hard to keep your bloodsugar levels close to the normal rangewithout physical activity. You arelikely to develop more nerve damageif your blood sugar levels are elevatedover many months or years. Exercisenot only helps physically, but helpspeople mentally and emotionally.Exercise is about so much more thanthe physical benefits (which in andof themselves are fabulous!). Exercisereleases those feel-good endorphines,and enables people to keep up withtheir grandkids!

What are some specific exercisesthat might help with pDPN?

My favorite is a leg extensionmovement that you can do whilesitting. Lift one leg at a time, andalternate. Feel the contraction of themuscle, squeezing and then releasing.I also like creative exercise with armssuch as lifing soup cans. There areendless exercises you can do withsimple items around the house.

Tell me something about yourexperience at TCOYD SantaClara last weekend.

I had lunch with some people withdiabetes and it was interesting to meto see that they were eager to learn,but shy to ask about physical activity.I think as soon as I started to ask

them questions, everyone realizedwhat they have in common, and that they understood each other.Everyone was hungry forinformation.

What are some tips for incorporating extra physicalactivity into your daily routines?

These days, we hire someone to do everything for us—from takingcare of the garden to washing the car.We ride escalators, drive everywhereand park as close as possible to ourdestination. All of these examplesare little opportunities for beingmore active. Get off at the earlier bus stop, park at the far end of thelot, carry a handbasket in the grocerystore instead of pushing a cart. Andon days when you are really tired,just get in some stretching.

Is there anything that peoplewith pDPN need to do beforethey start exercising?

See a doctor if you think you may have pDPN because there aretreatments available. Any physicalactivity can help with overalldiabetes management. Don’t beintimidated to start small. Let yourdoctor know you want to exercise.Find out what limitations you havefrom a medical standpoint but don’tuse those as excuses. If a particularexercise feels good thencommunicate that to the doctor.And finally, don’t be afraid toeducate yourself.

Where can people go for moreinformation on the Take theNext Step campaign?

www.diabetespainhelp.com

“By taking small steps, youmight be able to start

moving more and get backto doing the things thatmatter most to you.”[ ]

Feeling Low (continued from page 7)

the middle of the night when youare more likely to be both lowand groggy.

It is important to know when a low is coming on. Over time,many people tend to get used totheir early symptoms, making iteasier for those symptoms to goundetected. Some people evenlose the sensations completely.Educate your family or closefriends about the symptoms ofhypoglycemia so they can helpidentify low blood glucose in theevent that you are unaware of thesymptoms or are experiencingconfusion. Educate them aboutthe treatment of mild tomoderate hypoglycemia andteach them to use emergencyglucagon kits in severe situations.

Knowledge is power! Knowyour blood glucose values bymonitoring frequently, be awareof early warning symptoms ofhypoglycemia, know how to treat low blood glucose, prepareyourself with fast-acting carbohy-drate sources, and teach othersabout hypoglycemia! By knowinghow to prevent lows and by beingprepared if they occur, you candefinitely be in control of hypo-glycemia!


LETYOUR ENERGYLIFTYOU

O ften in life even when youdon’t know how you’re going to

accomplish something, you discoverthat just by having a firm intention,the “how” to get the job done showsup. You see with new eyes, hiddendoors seem to open, and solutionsappear out of nowhere. Intention isso powerful that just by intending tobetter control your diabetes, you will.Why? Because you will naturally takethe steps that support this intention.Invention can also help you with

your diabetes management. You caninvent yourself anew as someonewho manages diabetes well. Seeyourself in this new role by holding a mental picture of being a diabetes“pro.” See yourself performing yourtasks effortlessly. Feel how relaxedand confident you are. You canbecome better at managing yourdiabetes by returning to these imagesoften, or simply by taking healthieractions. Either way, you’ll be on thepath to becoming a new you.

Now let’s look at the power of illumination. You are illuminated, lit from within, when you realizesomething. For instance, if you knowyou don’t test your blood sugar asoften as you should, or that youcould be doing better with portion

control, allow that truth to burn sobrightly that it burns right throughall your excuses—and ignites yourintention to do better.

Last comes inspiration. Inspirationis a sense of excitement and purposethat comes from the center of yourbeing. Inspiration unleashes yourconfidence, strength and power toget the job done. To connect withyour inspiration, think about what

gives your life meaning and purpose. Intention, invention, illumination

and inspiration are powerful energyforces, and are an intrinsic part ofwho you are. If you begin to trustthem and invest in them, they canhelp you accomplish magical resultsbeyond your wildest imagination.

R iva Greenberg is the author of 50Diabetes Myths That Can Ruin YourLife: And the 50 Diabetes TruthsThat Can Save It and The ABCs OfLoving Yourself With Diabetes. Rivawrites for Diabetes Health magazineand has conducted more than 130interviews with people living withdiabetes, family members anddiabetes professionals to inform herwork and research.

“I was sitting at my first TCOYDevent in a workshop called“Coping with Diabetes” when mylife changed. The facilitator, CDEand psychologist, Bill Polonsky,looked at the hundred of ussitting there and asked, “How manyof you think diabetes is the leading cause of blindness, heartdisease, kidney failure and amputation?” We all put our hands in the air. “You’re wrong,”he said, “Poorly controlled diabetes is.” Those few words changed my life. It released mefrom the worry I had carried for three decades that these complications would be my fate,I realized how I manage my diabetes counts and so I began taking better actions. I’veheard Bill say that well managed diabetes is the cause of nothing. But here I have todisagree—although, in truth, I think Bill would agree with me—well-managed diabetesis the cause of a healthier and happier life.”– Riva Greenberg

THE LETTER IAN EXCERPT FROM THEABCS OF LOVING YOURSELFWITH DIABETES”


A RECENT NOTE SENT TO TCOYD

This is one of hundreds of notes we get at TCOYD about how the offer of scholarships and financial aid enables people to come toTCOYD’s educational and motivating programs. To every family,individual and company that makes it possible for TCOYD to do what we do, a giant thank you from the bottom of our hearts.

If you would like to make a donation, visit SupportTCOYD.org.TCOYD is a not-for-profit 501(c)3 charitable educational organiza-tion. All donations directly support TCOYD, are tax deductible andgreatly appreciated.

Is It Murder? (continued from page 5)

known to the prosecutor). There areenough innocent facts that the drivermight not be guilty of any. He wasclearly guilty of negligence, perhapsreckless, blood glucose management.But negligent or reckless bloodglucose management is not the same as negligent or reckless driving.Hypoglycemia is never intended andcan always become dangerous. Weknow a mistake was made wheneversevere hypoglycemia occurs. It islikely that virtually all of us who take insulin have at some time drivenwhile hypoglycemic; just as it is likelythat virtually all people who drivehave done so at some time whilesleepy or distracted or angry—all of which can result in a horrifyingaccident just as easily as hypo-glycemia.

In order to charge someone withcriminal behavior there must be some detail that makes the actionoutrageous; that shows the personwas irresponsible and not merelymistaken. Among other things, in acountry where so many have insuffi-cient access to medical care; whenthe standard of care in the medicalprofession does not call on healthcare providers to do nearly as muchas they should to warn individuals oninsulin how to drive safely and avoidaccidents; or when health coverageplans do not provide access to tools,such as continuous glucose monitors,that allow people with diabetes toavoid hypoglycemia in the first place,it is unfair to charge someone whowas not willful or reckless in causing

an accident to be branded acriminal.

This is not to say that those of us on insulin do not have our ownresponsibilities to know what we are doing and take precautionswhenever we drive, but rather, that amistake is still a mistake even whenthe consequence of that mistake istragic. And that such a mistakeshould not be deemed criminalmerely because of an awful result.

Let me add that although I havebeen involved to some extent inthree such cases, these cases are

extremely rare. Drivers with diabetesare not frequently getting in horridcar accidents because of insulin.However, those of us involved withdiabetes must also understand thateven one such accident is ahorrifying tragedy that cannot beundone. It is up to us to work toavoid it from happening, ever.

I received your flyer about the conference in San Diego on 10/24/09. I immediately called anddescribed a financialy stressful situation myhusband and I are in, but that we have greatinterest in attending—especially since my husband is a type 2 diabetic and my youngest daughter is a type 1 diabetic. Michelle told me to send in my registration and to send a check for whatever wecould afford even if it was just $5. I’ve included$5 for each of us, along with a great big THANKYOU for the generous donors who help to offsetthese expenses for families who are financiallystruggling right now.

– Kriss Halpern, one of TCOYD’s longestserving faculty members, spoke in 2009 atthe Milwaukee, Santa Clara and San Diegonational conferences on health care reformand its implications for people with diabetes.

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San Diego, CAPermit No 1

TCOYD Conferences & Health Fairs 2010 Schedule

February 6 Augusta, Georgia February 27 Sacramento, California March 20 Kalispell, Montana April 24 Honolulu, Hawaii April 25 Kauai, Hawaii May 8 New Orleans, Louisiana May 22 Raleigh, North CarolinaSeptember 11 Providence, Rhode IslandSeptember 25 Des Moines, Iowa October 30 San Diego, California TBA Native American Program

Taking Control Of Your Diabetes1110 Camino Del Mar, Suite “B”Del Mar, CA 92014 | www.tcoyd.org

Tel: (800) 998-2693 (858) 755-5683 Fax: (858) 755-6854

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there are so many other importantexternal influences.

The traditional ways professionalsare trained to take care of PWD will not change overnight. As anindividual living with diabetes, it is your responsibility to help directand focus your diabetes doctor visitso that you feel your most pressingproblems and concerns have beenaddressed. On the other hand, youmust be careful not to overpower or turn off your caregiver with abarrage of demands and a list ofquestions that is 10 feet long. There must be a balance betweengetting what you truly need and still allowing for what your trained professional needs to accomplishduring a typical health careencounter. Let’s all work patientlyand persistently together to re-define the diabetes doctor visit.

Doctor Visit (continued from page 2)

TCOYD is a not-for-profit 501(c)3charitable educational organization.

I n June, TCOYD’s partner,Mindeliver Media launched the

first national radio talk show dedi-cated to the management of diabetes.The innovative weekly program airson ReachMD SiriusXM 160 SatelliteRadio specifically targeting healthprofessionals. Dr. Edelman, recentlynamed Educator of the Year by theAmerican Diabetes Association, is the show’s host. Diabetes Discoursefeatures the latest developments indiabetes care, including new

treatments, exciting research and emerging technologies.

To date, Diabetes Discourse has generated a sizeable following.Average weekly listeners total280,000. The program is alsoavailable on iPhone. Please visit www.tcoyd.org for more on Diabetes Discourse andinformation on how to tune in.

MINDELIVER AND REACHMD LAUNCHDIABETES DISCOURSE HOSTED BYDR. EDELMAN

Documents

2009 Fall Vol 30