NEWSLETTERMY

As a caregiver, one of the biggest frustrations I have is when a patient comes back to clinic and has stopped his or her important blood glucose, hypertension, or cholesterol medications and says something like, “Was I supposed to refill it?” or “I went on vacation without my meds and I didn’t feel any different so I stopped taking them.”

Another situation that drives us caregivers totally bonkers is when people

with diabetes show up for clinic visits without their glucose testing logbooks or meters and say something like, “I didn’t think you wanted to see it” when, in fact, a patient’s logbook numbers are a vital component of the visit.

Why do so many folks with diabetes resist, even despise, being pro-active in managing their diabetes and find any reason possible to stop their medications? Some will even turn to vitamins or

Spring 2014 Volume 47

Make Love Not War (continued on page 2)

Dr. Edelman’s Corner

I can’t tell you how many times I’ve heard my patients make statements such as, “I hate taking all of these medications. How can I get off of

them?” or, “I hate my glucose meter (or continuous glucose monitor) and I want to run it over with my car!”

Make Love, Not War: Embrace The Medications And Devices That Will Keep You Healthy

INSIDE

The Couch Potato WorkoutPage 3

Treat Your Feet Page 4

Following The Trend Page 5

Running Toward A Cause Page 6

Novo Pen Echo AndRecipe From Chef Lewis Page 7

How To Count CarbsPage 8

Question Of The Month Page 9

Diabetes: The Impact On Family Members Page 10

Know Your NumbersPage 11

supplements that make unproven claims in fancy brochures because they seem more ‘natural.’ If it has the word ‘natural’ it has to be good, right? Well…strychnine is natural!

I could go on and on, but here’s the thing, every person with diabetes needs to embrace their medications and testing devices because these are the tools that will keep you healthy while living with diabetes. The harsh reality is that without these tools, diabetes can be deadly, especially if ignored and untreated. We are so fortunate to live in a time when all these tools are available to help us. Just 20 years ago, when we started TCOYD, there was only one medication for treating type 2 and two insulins for treating type 1. Today, we have nine different classes of medication for treating type 2 and an array of insulins for type 1. We can individualize treatment so that each person gets exactly what works best for them.

We know that proper glucose, blood pressure, and cholesterol control will help you avoid blindness, kidney failure, amputations and, let’s not forget, heart attacks and strokes. Preventing serious illness and disease is a blessing

2 My TCOYD Newsletter, Vol. 47

Board of DirectorsSteven V. Edelman, MD Founder and Director, TCOYD

Sandra Bourdette Co-Founder and Executive Director, TCOYD

Edward BebermanChristine BeebeAudrey FinkelsteinS. Wayne KayMargery PerryDaniel Spinazzola

Contributing Authors Jennifer BraidwoodSteven V. Edelman, MDRobert Lewis, ChefJeremy Pettus, MDCraig Wargon, DPM

TCOYD TeamSteven V. Edelman, MD Founder and Director

Sandra Bourdette Co-Founder and Executive Director

Jill Yapo Director of Operations

Michelle Day Director, Meeting Services

Michelle K. Feinstein, CPA Director of Finance and Administration

Jennifer Braidwood Manager, Outreach and Continuing Medical Education

David Snyder Manager, Exhibit Services

Robyn SemberaAssociate Manager, CME and Outreach

MyTCOYD NewsletterEditor: Jennifer BraidwoodAssistant Editor: Robyn Sembera Design: Hamilton Blake Associates, Inc.

MyTCOYD Newsletter is offered as a paid subscription of Taking Control Of Your Dia-betes. All material is reviewed by a medical advisory board. The information offered is not intended to constitute medical advice or function as a substitute for the services of a personal physician. On the contrary, in all matters involving your health, TCOYD urges you to consult your caregiver. ©2014 All rights reserved.

Make Love Not War (continued from page 1)

SpecialAcknowledgements

Steven Edelman, MDFounder and DirectorTaking Control Of Your Diabetes

not only to you but also, to your close friends and family, because it will be a tremendous burden on all of you if a serious problem develops. You owe it to yourself and your family to stay as healthy as possible for as long as possible.

Instead of resenting the fact that you need to take medicine and check

your blood sugars, look at it this way, your glucose meter or CGM device is your own personal laboratory right in the palm of your hand and that’s pretty darned powerful. People in earlier times would have given anything to be able to have such control over

their health. These devices give you so much information about your diabetes and put you in the driver’s seat. If you will make your diabetes a top priority in your life and learn to view your medications and devices as your friends, you will surely reap the reward of improved health.

Listen folks, stop whining and start embracing your medications and devices for what they are...your life-

saving and information-giving friends. And remember the old adage, Make Love, Not War!

Preventing serious illness and disease is a blessing not only to you but, also, to your close friends and family, because it will be a tremendous burden

on all of you if a serious problem develops. You owe it to yourself and your family to stay as healthy as possible for

as long as possible.

Taking Control Of Your Diabetes 3

TCOYD in Motion

e’ve all had that silent debate in our heads, the

one where you go over the pro’s and con’s of heading to the gym, for a walk or run, or cozying up on the couch and watching the latest episode of your favorite TV show. It’s a hard fight, but on the days where your workout routine takes a backseat to How I Met Your Mother or The Bachelor, we want to offer you a great alternative to being a total couch potato.

Every hour-long television program contains approximately six commercials breaks that last at least three minutes each. You can get a fantastic total body workout without missing a scene. Also, exercise during commercial breaks means you’re not snacking, which is also a big plus.

We turned to Prevention.com’s Couch Potato’s Workout because it’s great for beginners but it’s also good for exercisers of every level, since extra bouts of activity throughout the day help to keep your metabolism revved up.

Here’s what to do:Complete 10-15 repetitions of

each exercise and finish up with the aerobic component until the show starts again.

Commercial Break 1: Couch Pushups (chest and triceps)

Facing your couch, kneel on the floor about two feet away from it. Cross your ankles, and place your hands shoulder-width apart on a cushion edge. Slowly bend your arms, and lower your upper body until your chest touches the couch. Hold, then press up again. Aerobic: jumping jacks.

Commercial Break 2: Side Crunches (obliques)

Lie on your couch on your left side with you legs together and your knees bent. Place you right hand behind your head with your elbow toward the ceiling. Wrap your left arm across your waist. Contracting the oblique muscles along your right side, lift your shoulder off the couch, bringing your rib cage toward your

hip. Hold, then slowly lower. Repeat, then switch sides. Aerobic: run in place.

Commercial Break 3: Armchair Stands (quadriceps, gluteus)

Sit on the edge of your chair or couch with your feet shoulder-width apart. Without using your arms, press into the floor with your feet, and stand, tightening your butt muscles as you rise. Keep your abdominals tight and your back straight. Hold, then slowly lower yourself. Before you touch the chair, stand up again. Aerobic: walk or jog up and down stairs.

Commercial Break 4: Armchair Dips (triceps)

Sitting on the edge of your chair or couch, place your hands on the edge on either side of you. Move your feet out so that your butt is off the chair, and your knees are bent at 90-degree angles. Bending your elbows so they point behind you, lower yourself as far as comfortable. Hold, then slowly press up again. Aerobic: Circle your fists in the air to imitate boxing a punching bag.

Commercial Break 5: Leg-up Couch Crunches (abdominals)

Lie on your back on your couch with your knees bent, your feet up on one end, and your hands behind your head. Pressing your lower back into the couch, slowly lift your

The Couch Potato Workout (continued on page 7)

4 My TCOYD Newsletter, Vol.334 My TCOYD Newsletter, Vol. 47

Ask Your Podiatrist

t’s probably no surprise that people with diabetes can

sometimes find themselves having to deal with a number of different foot problems. Even ordinary foot problems like calluses, if not taken care of, can lead to some pretty serious complications. So, it’s really important to stay ahead of the curve and tackle issues as soon as you start to notice them.

Calluses can be a common issue for a lot people, even individuals who do not have diabetes. Calluses are most often the result of repeated friction or pressure and they can occur from improper fitting shoes, or if you have certain foot problems or deformities, such has bunions or hammertoes. Structural imbalances that are inherited can also lead to calluses, especially on the ball

of your foot. Some people have a greater propensity to form calluses than others, especially around the heel, which can lead to dryness or cracking. Because diabetes can

cause changes in the skin of your foot, calluses can occur more often and build up faster, and they can also be quite tender, which is a good thing.

You’re probably asking yourself, ‘why on

earth is tenderness a good thing?’ Because pain is your body’s alarm system and it lets you know when something is wrong. At some point in your life you have probably heard that people with diabetes can develop a condition called “peripheral neuropathy,” caused by nerve damage that often results in weakness, pain, and a progressive decrease of sensation in your feet.

Thick, hard calluses that rub against your shoes or the ground can actually puncture the skin. This is unlikely to happen to people with normal sensation in their feet because the feeling of pain would alert them to stop walking and address the problem long before it gets too serious. On the other hand, a person with diabetic neuropathy may not feel anything until it’s too late! The underlying skin may be punctured and an infection may have started without the person knowing. If untreated, this could lead to an infected diabetic ulcer, which is even worse.

Don’t worry, you can easily prevent these serious problems from happening by following just a few simple precautions and taking some time every day to treat your feet!

vKnow your diabetic foot risk level by asking your physician or podiatrist to test your protective sensation and circulation. If you have diabetic neuropathy or poor circulation, seek medical attention for your calluses from a podiatrist or other medical professional on a regular basis.

vWear proper fitting shoes with ample room in the toebox. Women of course, should avoid severely pointed or high heel shoes.

vOver the counter inserts such as Superfeet may help with calluses on the ball of the foot.

vUse a pumice stone (if you don’t have neuropathy) regularly

By Craig Wargon, DPM, Podiatric Surgery, Kaiser Permanente, Santa Clara, CA

Calluses can be a common issue for a lot people, even individuals who do not have diabetes. Calluses are most often the result of repeated friction or pressure and they

can occur from improper fitting shoes.

Taking Control Of Your Diabetes 5

CGM Study (continued on page 12)

after showering or bathing. Apply a moisturizer daily (avoid the area in between the toes).

vFor stubborn calluses, especially around the heels, consider a lotion that contains agents which chemically breakdown the callus (called a kertolytic). A common brand is Amlactin and is available over the counter. I often tell patients to apply this at night and cover the feet with stockings. This really helps drive the medicine into the troubled areas and softens the callus so that you can gently scrape off the top layer the next day with a pumice stone after bathing. This often needs to be done several days in a row until the callus is under control.

vBeware of “Eggs” and corn cutters. These ‘cheese grater’ or blade-like devices can be risky, especially for people with diabetes. It’s easy to slice off a healthy layer of skin with these types of products.

vAvoid so-called corn removers that contain salicylic acid in liquid or the adhesive form. These products can cause problems if used improperly.

vInspect your feet often. Be alert for signs of infection, which can include redness, draining, foul odor, swelling or obvious breaks in the skin.

vAnd last, contact your healthcare provider if you have any concerns.

(A Dexcom Study)

T he use of continuous glucose monitoring devices (CGMs) is

quickly becoming the standard of care when it comes to helping individuals with type 1 diabetes manage their condition. This is largely a result of more studies showing the clinical benefits of these devices including an ability to lower the A1c (typically on the order of 0.5%), reduce the amount of hypoglycemia, and increase the time being in a desirable glucose range. As studies continue to show benefits, more and more insurance companies are reimbursing for CGM devices with nearly all commercial payers covering the devices in type 1 diabetes, and some even expanding to type 2 diabetes.

However, a fundamental question remains: what are individuals with diabetes doing with the information provided by the devices to reach these beneficial outcomes? Keep in mind that CGM trials are different than your typical pharmaceutical

trial. Clinicians are very used to giving an individual with diabetes a drug and seeing what happens to the A1c; however, with CGM trials, clinicians are not specifically giving anything to the person with diabetes other than more information. Therefore, any change in A1c or reduction in hypoglycemia must be coming from something specific that CGM users are doing. So what are they doing?

To help answer these questions, we conducted a survey of 222 patients with type 1 diabetes who were deemed successful CGM users (wore the device for more than six days a week). They were asked 70 multiple-choice questions on varying aspects of their diabetes care. While patients made many adjustments in their care based on CGM values, the most striking findings were how they were adjusting their insulin doses based on the glucose trend information provided by their CGM devices.

By: Jeremy Pettus, MD, Endocrinology Fellow, UCSD, TCOYD Type 1 Track Co-Director

Following The Trend

6 My TCOYD Newsletter, Vol. 47

arbara Laskaris first got involved with TCOYD about

twelve years ago when she took her father, who has type 1 diabetes, to a TCOYD conference and health fair in San Diego, California. “I have watched my father’s health deteriorate through the years due to his resistance to change and refusal to manage his disease, so the cause of educating people with diabetes is very personal to me,” said Barbara.

In 2012, Barbara put together her first team of Ragnar Relay runners called “The Ambulance Chasers,” to participate in a 200-mile relay race that happens annually in Southern California. “Our team decided that if we were going to run, we were going to do something good for people in the process. Many of the team members have connections to the diabetes community and we felt that

TCOYD was an organization that could potentially benefit greatly from our efforts.”

This past year, The Ambulance Chasers went national and not only participated in their home race in Southern California that took place in April, but they also have plans to participate in both the Chicago Ragnar Relay and the Colorado Ragnar Relay.

So far, Barbara and The Ambulance Chasers have run close to 1,000 miles with the aim of supporting TCOYD and diabetes education and have raised close to $40,000. “Dr. Edelman’s mission to educate and empower people with diabetes to live healthier, happier lives and to take control of their disease through these conferences is such a powerful tool that has the capacity to reach so many people and change so many lives. I am proud to

Giving Back

raise money that I know will make a difference.”

You too can help TCOYD continue our mission of educating and empowering people with diabetes and help inspire others, so that one day we can all see a life free of diabetes.

Please make your gift today! Visit www.tcoyd.org and click on the “Giving” tab. If you are interested in joining The Ambulance Chasers Ragnar Relay team and supporting TCOYD or participating in other fundraising efforts, contact Barbara at BarbaraLaskaris@gmail.com.

By Jennifer Braidwood

Taking Control Of Your Diabetes 7

Product Theater

Ingredients: 2 carrots, diced4 mushrooms, diced1 red pepper, diced1 large onion, diced

Preheat the oven to 425 degrees. Spread vegetables in a single layer on a sheet pan, drizzle on the oil, and mix with your hands to evenly distribute the oil. Roast for 30 minutes, stirring them halfway. Pour the tomatoes and thyme over the vegetables and roast another 15 minutes, just until the tomatoes and the vegetables have turned slightly golden brown. Remove thyme stems. Use a spatula to transfer the vegetable and tomato mixture into a large saucepan, then slowly add the stock. Season with pepper and simmer for 10 to 20 minutes. Add the kale and the cannellini beans and simmer 5 minutes, until the kale has wilted. Add the parsley, stir to combine, and remove from heat. Serve warm. Serves 6

Chef Robert Lewis, ‘The Happy Diabetic’ was diagnosed with type 2 diabetes in 1998. Chef Lewis has published three cookbooks – Cook Fresh, Live Happy; Get Happy, Get Healthy; and Simply Desserts.

1 can drained cannellini beans1 small butternut squash, peeled, seeded, and chopped3 garlic cloves2 tsp canola oil2 sprigs fresh thyme

Farmers’Market Roasted

Vegetable Soup

Novo’s new insulin injective device, the NovoPen Echo, is the first and only pen device available in the United States that provides

both precise and half-unit dosing. The NovoPen Echo also has a memory function that records the dose and time passed since the last injection for extra reassurance. It can remind busy teens, parents, caregivers, or adults on the go, when and how much their last dose was.

The half-unit dose increments allow for finer adjustments, which can be particularly important for children. In addition, twelve fun removable skins are available for a customized look, including kid-friendly designs.

Here’s an overview of features that are available on the NovoPen Echo:

The NovoPen Echo From Novo Nordiskhead, shoulders, and upper back

off the couch. Hold, then slowly lower. Aerobic: Knee lifts. While standing, alternate bringing your right elbow down to meet your left knee, and vice versa.

Commercial Break 6: Scissors (adductors and abductors)

Lie on your back on your couch (you may need to angle yourself for more room) with your hands (palms down) under your butt and your legs straight up in the air. Keeping your knees slightly bent and your feet flexed, slowly spread your legs as far apart as comfortable. Hold, then slowly bring your legs together, resisting as you press them in. Aerobic: Side slides. Step your right foot out to the side, then slide your left foot to meet it. Repeat in the opposite direction, doing this as quickly as you can.

The Couch Potato Workout(continued from page 3)

Half-unit dosing: u Fine-tune your dose from 0.5 units

up to 30 units for precise dosing that works with even a small snack

Memory function: u Automatically records the dose and

time since your last injection

Dials and exact dose: u The dose button can turn backward

and forward to help you choose the right dose without wasting insulin

u You can dial your dose up and downu You’ll know when to change the cartridge

because NovoPen Echo doesn’t allow you to dial anymore units

u You may hear or feel an end-of-dose click

Short button travel: u Reduces injection movement

Ready-to-change PenFill cartridge: u PenFill cartridges are sold separately

1 14oz can no salt added diced tomatoes32 oz no salt added vegetable stock1/2 tsp black pepper1 1/2 cup kale, shredded1/4 cup chopped parsley

Per Serving: Calories: 134 • Total Fat: 2.39g • Dietary Fiber: 8.05g • Protein: 7.35g

• Total Carbs: 26.44 • Sugars: 5.37g

u Coleslaw: 1/2 cup = 15g carbu Potato salad: 1/2 cup =

22-30g carb

6. Study sandwich standards. Although there are countless ways to build a sandwich, the bread used as the base contributes most of the carbohydrate. Follow this guide for estimating the carbohydrate in sandwiches made with typical savory toppings.u Breakfast meat on English

muffin: 30g carbu Burger on standard-size bun:

30g carbu Sandwich made with sliced

bread: 45g carbu 6-inch submarine sandwich:

45-60g carb

Counting carbohydrates in dishes made with multiple

ingredients is a cinch when you have measuring cups and nutrition facts at your fingertips. Here’s help for times when your only clue is how the food looks on your plate.

8 My TCOYD Newsletter, Vol. 47

Taking Control

1. Count hot dishes by the cup. A mix of meat with vegetables in a savory sauce, including stew and many Asian food entrees, has around 15 grams carbohydrate per cup. For dishes made with pasta or grains, such as lasagna or chicken with rice casserole, count 30 grams carbohydrate per cup.

2. Think: spoonable or forkable?If soup is so thick and hearty you could nearly eat it with a fork, such as Ramen noodles, or if it’s loaded with legumes, such as chili or split pea soup, estimate 30 grams carbohydrate per cup. Broth-base soups and cream soups made with water average 15 grams carbohydrate per cup.

3. Scan with your hand. An adult’s hand, when spread, typically spans 7-8 inches from thumb to pinky finger. That’s the width of a medium flour tortilla, which has 20-25 grams carbohydrate. Use your hand to size

up tortillas at burrito bars. Some are as much as 13 inches across, packing 55 grams carbohydrate—not counting the filling.

4. Calculate pizza by the crust, which is where most of the carbohydrate is. A medium (12-inch) thin crust pizza topped with sauce, vegetables, cheese, and meat, that’s cut into 8 pieces has 20-25 grams carbohydrate per slice. A regular crust pizza averages 30 grams carbohydrate per slice.

5. Identify main ingredients in salads to estimate the carbohydrate count. If your favorites are higher in carbohydrate (and creamy with lots of fat), opt for a smaller serving. Here’s how common salads stack up:u Leafy garden salad (without

dressing): 1 cup = 2-5g carb u Meaty salad (such as chicken,

tuna, or egg): 1/2 cup = 7g carb

How To Count Carbs In Combo

Article provided by Diabetic Living® Magazine

7. Count a “bread” for breaded meats. “Naked” meat that’s grilled or broiled is carbohydrate-free (and generally lower in fat). But if a breaded chicken patty or serving of six chicken nuggets is your treat, count 15 grams carbohydrate to account for it. For larger breaded meat patties, such as country-fried steak, count 30 grams carbohydrate.

8. Limit appetizers to one piece. A single Thai spring roll, an Italian bread stick, or a lettuce wrap provides about 15 grams carbohydrate—not counting dipping sauces. Want an appetizer meal? The total calories and carbohydrate in an appetizer often equal (and sometimes surpass) an entrée, so if you order multiple dishes, split them with friends.

9. Tally tablespoons. When served family-style, such as at an Italian restaurant or steakhouse, use a tablespoon to size up servings as you put food on your plate. For example, 4 level tablespoons (1/4 cup) baked beans add up to 15 grams carbohydrate and 8 tablespoons (1/2 cup) corn provide 15 grams carbohydrate.

10. Triple the carb count when fruit is made into dessert. A small apple or 3/4 cup blueberries has only 15 grams carbohydrate, whereas just 1/2 cup apple crisp or 1/8 of a blueberry pie has 45 grams carbohydrate. To make room for these occasional treats, choose low carbohydrate foods for the rest of the meal.

By Steven Edelman, MD

Taking Control Of Your Diabetes 9

I don’t ever get up in the middle of the night to snack; however, my morning blood glucose is sometimes higher than it was at bedtime.

Why is this?

Answer: Although this seems to be a more common concern in people with type 1 diabetes, this can often times happen with people who have type 2 as well. Higher morning blood sugars are commonly due to the “Dawn Phenomenon.” The Dawn Phenomenon refers to the natural release of excess hormones, such as the growth hormone, in the morning between 5 am to 8 am. This results in an increase of the blood sugar levels at dawn, or early morning. Less commonly, one can have high blood sugars in the morning as a protective response to low blood sugars during the middle of the night. This is referred to as the, “Somogyi Effect.” Another reason for a high blood sugar in the morning is that you may simply need a higher dose of your usual diabetes medication (insulin and/or pills). Lastly, another explanation for a higher glucose level in the morning compared to your bedtime value the night before is a complicated metabolic term called excessive hepatic (medical term for liver) glucose production. The liver inappropriately produces too much glucose at night and is very commonly seen in people with type 2 diabetes. In the latter situation, basal insulin and oral medications such as metformin may be needed.

A special thanks to all of our Facebook fans who sent in questions for Dr. Edelman!

Question of the Month

Taking Control Of Your Diabetes Is Generously Supported By:

Platinum Corporate Sponsors

Silver Corporate Sponsors

Gold Corporate SponsorsPlatinum Foundation Support

Managing your diabetes requires a lot of you. Maintaining a healthy diet, getting

the right amount of exercise, keeping up with your medication regimen, checking your blood sugar levels, and making decisions with your health care team are just a few things that you have to do regularly to maintain control. It’s understandable that this can be overwhelming at times. But remember that you are not alone!

Your family members should be an integral part of your team and provide you with support through the ups and downs of living with diabetes; however, it’s important to keep in mind that the weight of living with diabetes that you may sometimes feel, your family members probably feel, too. By involving your family in your diabetes care and management, they can significantly impact how well you self-manage your diabetes and your overall experience. In addition, your family will feel more involved, less burdened, worried, or frustrated. What it comes down to is, diabetes is truly a family affair!

The Hidden Impact on Family MembersA recent global survey study looked at the

experiences and unmet needs of people with diabetes, their family members, and health care providers. This study was called Diabetes Attitudes, Wishes and Needs 2 (DAWN2™). It was the first large study to look at the impact of diabetes on family members from these perspectives. Diabetes is known to be a burden for people living with diabetes; what these findings brought to light is the hidden impact of diabetes on family members.

10 My TCOYD Newsletter, Vol. 47

Living Well

Shedding A New Light On Diabetes: The Impact On Family Members

notes, listening, and being there for support

v Talk more openly about how you are feeling, what questions or concerns you may have, and what your needs are

v Eat healthy meals together and be active together

v Find educational and support programs (including support groups)

Key findings showed that many family members reported: v Feeling burdened and

distressed v Worrying about the risk of

hypoglycemic events v Feeling frustrated that they

do not know how to help the person they care for

v Wanting to be more involved in the care of their loved one

v Having a need for more psychosocial support and education

v Feeling a positive impact on at least one aspect of their lives, such as healthier eating habits

For more detailed information about the global surveys, DAWN™ and DAWN2™, as well as for practical tools and resources, visit www.dawnstudy.com.

Teamwork is The Key to SuccessWhen it comes to uncovering

the impact that diabetes has on family members, the DAWN2™ study is just the beginning. More research needs to be done to learn about the psychosocial impact of diabetes and ways to address the unmet needs of both people with diabetes and their family members. Remember, invite your family members to be a part of your team. Here are a few tips you can try: v Ask a family member to go to

doctor’s appointments with you. They can help by taking

By Steven Edelman, MD

Taking Control Of Your Diabetes 11

Know Your Numbers

When you take a look at the logbook below, it’s perfectly obvious that the fasting and bedtime blood sugar values are consistently high.

Many caregivers would immediately increase the evening or bedtime insulin and/or oral medications to improve the morning levels. What is important to recognize here, is the main problem may be that this person is going to bed with levels that are too high. If the blood sugar values were in the mid 100’s at bedtime, the morning values may also fall within the desirable range with no change in the evening insulin dose or oral medications.

The first thing to do is to figure out why the bedtime numbers are so high and correct the problem, which could be a few things: not enough fast-acting insulin with dinner, too large of a meal at dinner time, or snacking after dinner. Once the bedtime numbers come down, at least under 200mg/dl, then it is important to watch the morning numbers to see if they also improve. An old rule in diabetes management is to make one change at a time.

You have to work together, and communicate together. Remember, you are not alone, and your care team is there to support you. By putting these strategies into practice together, it can benefit the entire family!

DAWN™ and DAWN2™ are trademarks and Changing Diabetes® and the Apis bull are registered trademarks of Novo Nordisk A/S.© 2014 Novo Nordisk All rights reserved.0314-00020383-1 April 2014

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PAIDSan Diego, CAPermit No 1

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

Stay connected to TCOYD, visit www.tcoyd.org

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

TCOYD Conferences & Health Fairs 2014 Schedule

February 8 Native American, Pala, California March 8 Sacramento, California April 12 Honolulu, Hawaii May 17 Raleigh, North Carolina June 7 Washington, DC September 6 Missoula, Montana September 27 Des Moines, Iowa October 18 Amarillo, Texas November 8 San Diego, California

12 My TCOYD Newsletter, Vol. 47

One major advantage of CGM devices is that they not only give you what your glucose level is, but also where it is going in the form of a rate of change (ROC) arrow. Take the two different scenarios that we presented to our survey patients shown in figures A and B. Notice that in both figures the absolute glucose value is the same at 220mg/dl. However, in Scenario A the glucose is rapidly rising, and in Scenario B the glucose is rapidly falling. This is extremely important information that only a CGM device can provide as a typical finger stick only gives you the absolute

number and not a trend. With these scenarios, patients surveyed reported that they would more than double their typical insulin correction dose in response to Scenario A. On the flip side, they would either drastically reduce their insulin dose or not take any at all in response to Scenario B. In other words, with the same glucose of 220mg/dl, the response could vary dramatically from not taking any insulin at all to taking a larger than normal dose, ALL depending on the ROCs.

This is a phenomenon that people with diabetes have been noticing long before the advent of CGMs. Individuals with diabetes would frequently say that sometimes they

would bolus and nothing would happen or sometimes they would bolus and their glucose would crash. This likely has a lot to do with where their glucose was heading prior to that insulin dose. If it’s going up, the dose will have more work to do and appear to not have an affect. If it’s going down it will appear to be more effective.

What it comes down to is, with the help of a CGM device you can anticipate where your glucose levels are headed at any given time, and make some rather large adjustments to your insulin dosing; that will ultimately lead you to much better control. So, if you haven’t done so already, be sure to talk to your doctor about the benefits of getting a CGM.

CMG Study(continued from page 5)