diatribe - research and product news for people with diabetes - issue #5

8/14/2019 DiaTribe - Research and Product News for People With Diabetes - Issue #5

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conference pearls

American Diabetes Association 67thScientific Sessions (Chicago, June 22-26, 2007)

In late June, diaTribe sent our team to Chicago to attend the 67th Annual Scientific

Sessions of the American Diabetes Association. Referred to simply as ADA, this meeting

is the biggest in diabetes; this year over 11,000 researchers, doctors, educators, nurses,

dieticians, and other professionals gathered to present new scientific data, hear fromclinical thought leaders, and generally expand the

knowledge base in diabetes. We came back from

the grueling five-day meeting exhausted but newly

optimistic about ongoing work in diabetes care as well

as the many exciting new drugs and products that we

expect to become available within the next few years.

See below for our ADA pearls!

Pumps, patches, and ports new insulin

delivery technologies for type 2s are just

around the corner. One interesting trend this year

was the large number of small companies working on

new insulin-delivery technologies that may provide

affordable alternatives to injections within the next few

years. The h-Patch is a disposable insulin patch pump

for type 2s being developed by Valeritas; this device

would be simpler to use than traditional insulin pumps.

Each h-Patch lasts a day, after which it is discarded.

The patches infuse a fixed basal rate of insulin but also

have the ability to deliver additional units as needed

for meals. We think this technology has the potential to

make it easier for type 2s to go on basal-bolus insulin

therapy although it would not be appropriate for type 1patients because each pump uses a standard basal rate that patients are unable to change.

Alternatively, insulin ports are another way of getting around injections; these are similar to

the infusion sets used for insulin pumps, removing the need to give many daily injections;

patients would only need to pierce their skin every few days when it came time to change

the port. We believe this would also be very useful for patients interested in using Symlin

(see our Learning Curve on Symlin in diaTribe #3) to reduce their post-meal blood glucose

levels but who dont want to take more shots per day.

V O L U M E 1 I S S U E 5

Conference Pearls .......... 1

ADA and CWD two big

meetings of 2007

From the Editor .............. 2

What a summer.!

FingerSticks ................... 2

Inhale, exhale

Test Drive ........................ 7

Jim Hirschs candid take on

the Omnipod and the SEVEN

Diabetes Dialogue ......... 9

Jeff Hitchcock and the

inspired, inspiring Children

with Diabetes organization

Logbook.......................... 15

A challenge to the Acting

Surgeon General

Learning Curve ............... 17

Olive oil, wine and the

French Paradox

Profile .............................. 19

Chronic disease: working

extra hard to work

Trial Watch ...................... 21

Sign me up!

What Were Reading ...... 22

So you dont have to!

NewNowNext ................ 23

Whats in

in this issue

research and product news for people with diabetes

To subscribe todiaTribe, visit

www.diaTribe.us.1continued on page 3

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from the editor

From conferences to Avandia to burritos...What a trip!

Happy day! We are all in terrific moods here at diaTribe as

the summer ends weve attended some great conferences,

read some wonderful research papers, and had some terrific

conversations with leading doctors, nurses, and scientists. Were all in

the diaTribe offices just winding down on a Friday afternoon, drinking a beer and thinking

about how lucky we feel. Thanks to all of you for checking in let me tell you about this,

our fifth issue of diaTribe!

Weve been thinking big thoughts about diabetes since we returned in late June from

the American Diabetes Meeting (ADA) in Chicago there was so much to see! Eight of us

traipsed around the city for four days taking in news on type 1 diabetes, type 2 diabetes,

exercise, lifestyle, psychology .. you name it, if it concerns diabetes, we looked, listened,

took notes, and discussed it! We also went to the Children With Diabetes Meeting in

Orlando and felt more hopeful about diabetes than we had all year see why inside.

For our Test Drive, our gadget-avoiding Jim Hirsch tells us about his experiences withdisposable pumps and continuous sensors. It isnt always pretty, but it is encouraging. Find

out how he fared on page 7.

Thats it from San Francisco weve finished our beers and most of the team is off

to find some of San Franciscos finest food in the form of burritos in our Mission district!

Im running to find baby Lola, Coco, and John and to thank them again for an amazing

summer. Cant wait to see you next time if you have anything on your mind, or ideas for

diaTribe, as always dont hesitate to write me at [email protected].

Yours,

Kelly

fingersticks

D I AT R I B E R E S E A R C H A N D P R O D U C T N E W S F O R P E O P L E W I T H D I A B E T E S

2

diaTribe staffEditor in Chief

Kelly L. Close

Managing Editor

James S. Hirsch

Contributers

Kaku Armah

Daniel Belkin

Michael Chen

Jenny Jin

Amy TenderichDaniel Trecroci

Mark Yachoan

Design

Gina Wilson

diaTribeadvisory board

Jennifer Block, RN, CDE

Dr. Zachary Bloomgarden, MD

Dr. Bruce Bode, MD

Dr. Nancy Bohannon, MD

Dr. Bruce Buckingham, MD

Dr. Wendell Cheatham, MD

Dr. Steven Edelman

Dr. Barry Ginsberg, MD, PhD

Debbie Hinnen, ARNP,

BC-ADM, CDE

Dr. Irl Hirsch, MD

Jeff Hitchcock

Dr. Lois Jovanovic, MDDr. Francine Kaufman, MD

Dr. Aaron Kowalski, PhD

Mirasol Panlilio

Dr. William H. Polonsky, PhD

Michael Robinton

Jane Jeffrie Seley, NP, CDE

Virginia Valentine, CNS,

BC-ADM, CDE

Dr. Howard Wolpert, MD

Gloria Yee, RN, CDE


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What to do about Avandia? An expert panel weighs in. More than four thousand

doctors packed into an enormous auditorium to hear from Cleveland Clinic cardiologist Dr.

Steven Nissen, the author of the original paper that started the Avandia controversy. As

readers probably saw in the popular press, this paper suggested that Avandia, an insulin

sensitizer commonly used for type 2 diabetes, increases the risk

of heart attack by 43%. Other expert panelists at this symposium

included Dr. Philip Home, a well-known UK researcher; Dr. John

Buse, the highly regarded president of the American Diabetes

Association; Dr. David Nathan of Harvard Medical School; Dr.

Barry Goldstein of Thomas Jefferson University; and moderator

Dr. Richard Kahn of the American Diabetes Association. The panel

was not able to answer the question of whether Avandia is actually

harmful we simply do not have rigorous clinical trial evidence

to decide one way or the other but Dr. Kahn did pose a very

interesting three-part question to his colleagues: What would you

do with 1) a patient who is not on Avandia, 2) a patient who is ingood glycemic control on Avandia, and 3) a patient who is not in

good control on Avandia? Dr. Buse led the panelists in recommending that 1) someone

who isnt taking Avandia yet should be started on one of the many alternative medications

available, 2) someone who is doing well on the drug should remain on it until we know

more about it, and 3) someone who isnt doing well on Avandia should be evaluated for

therapeutic intensification and possibly discontinuation of the drug.

An FDA panel met July 30 to deliberate on the controversy and on August 14, a black

box warning was issued for Avandia as well as Actos, a drug from the same class (called

thiazoladinediones). The warning emphasizes that the drugs may cause or exacerbate heart

failure, especially in certain patient populations. Both drugs will, however, remain on the

market this warning doesnt address heart attack risk, the risk originally raised by Dr.Nissen. We believe all patients should make sure their healthcare team is watching out for

safety first if you have not done so recently, we encourage you to check in with your

healthcare team to make sure you are on optimal therapy. If your A1c is over 7 and your

therapy has not changed in more than six months, your doctor or educator may wish to

optimize your routine they will be the best judge, but as always, it is very important for

you to follow your own progress and to manage your diabetes to the best of your abilities.

A new paradigm for continuous glucose monitoring (CGM): Improving

A1c without increasing hypoglycemia. One of the most important trials presented

this year was the STAR 1 study, the first randomized controlled trial to compare continuous

glucose sensor-augmented pump therapy against traditional insulin-pump therapy without

CGM. Dr. Irl Hirsch from the University of Washington gave a brisk presentation to a

packed auditorium of more than a thousand professionals. The trial enrolled 138 adults and

adolescents with type 1 diabetes; all were already using insulin pumps. These participants

were randomized into two groups. One began wearing the Medtronic Paradigm 522/722

pump, which can be used with a real-time CGM sensor. Continuous glucose data were

displayed in real time on their pump screens. The other group went on the Paradigm 715

smart pump, a standard insulin pump without CGM. After six months, A1c dropped from

8.5% to 7.8% in both groups, but only the CGM group was able to do so without an increase

in hypoglycemia. University of Virginia mathematician Dr. Boris Kovatchev nicely summed

up this finding when he said that we should think of CGMs primary benefit as the ability to


3continued on page 4

The panel was not able

to answer the question

of whether Avandia is

actually harmful we

simply dont have

rigorous clinical trial

evidence to decide one

way or the other.

PHOT

O:MARKYARCHOAN

Doctors Refuel on Diabetes Research at ADAcontinued from page 1

Tough inter-booth competition

as drug and device companies

battle for the attention of

healthcare providers.


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reduce hypoglycemia; this in turn allows patients to intensify therapy and reduce A1c and

long-term complications. We note, however, that to everyones surprise, in STAR 1 there

were actually more episodes of severe hypoglycemia in the CGM group than in the control

group (11 vs. 3). In case your doctor might note this or might seem otherwise unenthusiastic

about the study results it is key to know that Dr. Hirsch attributed this result to unique

problems that occurred at one of the study sites rather than to the use of CGM itself. STAR

1 was the first of three major trials that Medtronic is sponsoring to show the benefits of

continuous glucose monitoring. The trial was at least in part intended as a practice study

to help the research investigators prepare for the current STAR 3 trial. STAR 3 is the largest

of Medtronics CGM trials the yearlong trial was expanded recently to 550 patients - and

will likely also be the most important one in helping convince insurance companies to pay

for CGM. Unlike STAR 1, it will compare sensor-augmented therapy against multiple daily

injections (MDI) of insulin guided by fingerstick glucose values it is comparing against

MDI rather than standard pump therapy because MDI is still the way most type 1 patients

take insulin.

For Byetta enthusiasts who wish they could take fewer injections, next-

generation incretin therapies are on the way. The next big drugs in the GLP-1

class to which Byetta (exenatide, made by Amylin/Lilly) belongs will be liraglutide (Novo

Nordisk) and Byetta LAR (Amylin/Lilly), which stands for Byetta long-acting release. Bothare expected to be on the market around 2009 see this issues What Were Reading for

more details on how they work. Liraglutide will be a once-daily injection with a fine needle,

while Byetta LAR will be a once-weekly injection with a slightly wider needle. Just before

ADA began this year, Novo Nordisk released some intriguing data from a large six-month

trial for liraglutide. In this trial, liraglutide produced a 0.2% greater A1c drop than Lantus

insulin in patients not achieving their A1c goal on metformin and/or sulfonylureas. Oral

medications like metformin and sulfonylureas are rarely enough to keep type 2 patients

at A1c goal for more than a few years, after which insulin therapy becomes necessary.

However, in the future it may become common practice for patients who have stopped

responding to oral medications to try a GLP-1 drug like Byetta or liraglutide before going on

insulin.Unlike insulin, which causes weight gain, GLP-1 drugs are associated with weight loss,

though the actual amount of weight change varies greatly among individuals. Dr. John

Buse, ADA president, presented new data showing that patients in the original phase 3

Byetta trials who continued taking Byetta for three more years continued to lose weight

and maintain the same A1c drop that they had after six months of Byetta treatment. These

are very promising results, especially since the current twice-daily formulation of Byetta

is actually degraded too quickly to provide 24-hour effects. Byetta LAR should overcome

this problem, which is why clinicians are excited to see the results of the currently ongoing

large phase 3 study of Byetta LAR. If the results from a much smaller trial with Byetta LAR

hold up, the once-weekly formulation could produce greater A1c improvements (perhaps a

drop of 1.7% in A1c, as seen in the smaller trial) and weight reductions than the twice-daily

formulation. Amylin/Lilly stated they expect to release the results of ongoing phase 3 study

of Byetta LAR well update you when they do

Why Janumet may be better than Januvia. Researchers from Merck, which

makes both of these drugs, presented some interesting data that suggest metformin

and Januvia (sitagliptin) may have synergistic mechanisms of action. Januvia belongs

to the DPP-4 inhibitor class of drugs, which work by inhibiting the action of the DPP-4

enzyme, which breaks down GLP-1. The net result is that it works by increasing the level of

active GLP-1 in the bloodstream by about two-fold (Byetta effectively raises GLP-1 levels

considerably more, which is why it produces different effects than Januvia). Metformin



The combination pill, Janumet

STAR 3 is the largest of

Medtronics CGM trials

and will likely also

be the most important

one in helping convinceinsurance companies to

pay for CGM.


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is one of the oldest diabetes drugs on the market, but its mechanism of action remains

somewhat of a mystery. This year, researchers revealed that metformin also raises levels

of GLP-1 in the bloodstream by about two-fold, but while Januvia works to prevent the

breakdown of active GLP-1, metformin seems to increase the total production of GLP-1.

Thus, when taken together (i.e., Janumet), the two drugs produce an additive effect on

GLP-1, increasing levels by about four-fold. This may account for why Janumet produces

a more robust A1c drop than either metformin or Januvia alone. The ADA recommends

metformin as first-line therapy for type 2 diabetes, followed by either a sulfonylurea(generic), a thiazolidinedione (Actos or Avandia), or basal insulin (Lantus or Levemir). At

the time of the recommendation, Januvia was not yet approved by the FDA, but these new

data suggest that Januvia might not be a bad idea for combining with metformin in patients

who dont reach A1c goals on metformin alone.

No one is safe from hyperglycemia, especially during pregnancy. The results

of the HAPO study were alarming for people both with and without diabetes. HAPO was

the first study to ever look on a wide scale at pregnancy in women without diabetes. The

investigators discovered that there were no cut-offs for increased risk when it came to

glucose values. In other words, women with fasting plasma glucose values from 75 mg/dL

to 100 mg/dL showed a linear relationship between glucose level and adverse pregnancy

outcomes (note that 100 mg/dL is the cut-off for prediabetes and 126 mg/dL is the cut-off for diabetes). These included outcomes for the probability of the baby being large for

gestational age (LFGA), rates of primary C-section, neonatal hypoglycemia in the newborn

baby, and unusually high levels of insulin production. These findings are a reminder that

we should all be striving for glucose levels as near to normal as possible, even before we

reach diagnostic cut-offs for prediabetes and diabetes; to a certain extent, these cut-offs are

only arbitrary values especially during a pregnancy.

See even more Pearls online at www.diatribe.us/issues/5/conference-pearls.php.

Children with Diabetes Friends for Life

Conference and Expo (Orlando, July 11-15, 2007)Friends for Life, the national Children with Diabetes (CWD) conference, took place inOrlando, Florida, from July 11 to July 15. The conference exercised both mind and body

while experts discussed the latest treatments in diabetes, professional athletes ran sports

camps. The exciting exhibit hall featured the latest continuous glucose monitors, insulin

pumps, and tasty sugar-free products. In the midst of it all, we had our diaTribe stand.

See our Dialogue with founder Jeff Hitchcock for more on how the conference began!

There is often a gap between the advice from health care providers

and what patients actually understand. This dearth of health literacy was the

focus of US Surgeon General Ken Moritsugus keynote speech. We thought long

about his message: to close the gap, both parties need to work toward bettercommunication. It is challenging because much of the time, healthcare providers

are pressed for time if your doctor is not, you are among the lucky! We do

strongly encourage working with a diabetes educator no matter how good your

diabetes management is. They can help you figure out how to improve your

management and can probably even give some communication advice not

only with your doctor but also with your friends and family. Moritsugu also encouraged

patients to make a point to stay informed about the goings on in the world of diabetes. We

at diatribe urge you to check out diabetes resource dLife at www.dLife.com where you can

ILLUSTRATION:DANIELBELKIN

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find nutrition information, recipes, and even MSNBC Hardballs Chris Matthews talking

about his experience with diabetes. We would absolutely agree with Moritsugu that you

should work to close the communication gap by using your knowledge and experience to

help others. For more on what Moritsugu shared, see this months Logbook.

Ready, set, pump! Dr. Henry Anhalt, a noted pediatric endocrinologist and

CDE spoke extensively about Why we pump. He said his type 1 patients would

insist that they were accurately delivering fractional insulin doses with a regular syringe

but would fail miserably in a reproducibility test. As many readers know, and as Dr. Anhalt

stressed, insulin pump therapy allows you to deliver exactly how much you need, and leads

to better glycemic control. Better control of course means lower risk of both micro and

macrovascular complications. Dr. Anhalt discussed pumping for children in particular;

since school nurses are not allowed to give insulin shots, some parents find it difficult

putting their children on an optimal MDI schedule, and pumping is one solution that many

parents find helpful.

The artificial pancreas, a device-based cure, is on everybodys mind.

Dr. Aaron Kowalski, who is leading the effort toward the artificial pancreas by the JDRF,

talked about the current state of the art. The ultimate iteration of the artificial pancreas

will be a closed loop, fully automated insulin delivery system based on continuous

glucose monitoring. In this context, a closed loop refers to the device systems capacity towork effectively to maintain healthy glucose levels without any input from the wearer it

would be like having an electronic pancreas. Earlier versions will be a hybrid closed loop,

requiring at least some input from the wearer; a closed loop is extremely difficult to achieve

for many reasons. For example, in non-diabetic patients, simply thinking about or smelling

food starts the pancreas producing insulin. The device system, at least with current

monitoring technology, cannot replicate this. It must be reactive to changing glucose levels,

rather than proactive like the non-diabetic human body, resulting in imperfect timing of

insulin delivery and a perpetual game of catch-up. On the other hand, a hybrid closed loop

allows wearers the option of manual bolusing before meals to eliminate the catch-up factor

Other barriers to a true closed loop from our perspective include the availability of a top-

notch sensor the current ones are getting much better but still have issues with accuracy(especially at low levels), the availability of very good algorithms (in development), and

timing there is still a lag between the time that insulin goes into the system and the time

it begins working and with a perfect artificial pancreas there wouldnt be a lag, just as there

isnt in non-diabetics. But heres to progress we do feel like there is much more of it in the

last year or two and were excited about the research on this front, since most patients have

been hearing this is about five years away for decades!

People with type 1 diabetes do not need more insulins; they need smarter

insulin. The current insulin therapies can require over 30 minutes to reach their peak

activity. That means ideally when you see a movie, you take your insulin, watch the first 30

minutes of the movie, and then start eating your popcorn. Dr. Irl Hirsch, insulin expert at

University of Washington commented on Biodels Viaject, a new subcutaneously injected

formulation of insulin, noting that this insulin may be absorbed much more quickly it is

in phase 3 tests and is expected to be available by 2009. Well be looking out for this.

And on a related (or not) note whats the weirdest injection site you can

think of?According to Dr. Irl Hirsch, there is research being done to find alternative

routes for insulin administration. These include ocular, rectal, intra-vaginal and per lingual

(through the tongue) routes. Current insulins are not fast enough, but they act faster or

slower depending upon the injection site due to differing rates of absorption per site. There

is even some research to suggest the scrotum is one of the more optimal places to inject! Do

not try this at home.

The current insulin

therapies can require

over 30 minutes

to reach their peak

activity. So when you

see a movie, you take

your insulin, watch the

first 30 minutes of the

movie, and then start

eating your popcorn.


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test drive

A Technology Laggards Foray into Insulin Pumpsand Continuous Sensors

By James S. Hirsch

Its fair to say that Im a technology laggard and that even on my best days I have alove-hate relationship with gadgets. Im not even on speaking terms with my cell phone.

But two years ago, I began using an insulin pump, primarily because I had a bad low and

figured I needed to so something different. I went on the Animas. Then earlier this year,

Roche wanted feedback on its new Accu-Chek pump, so I tried that for four months.

When that trial was over, I took another detour and bought the OmniPod, which

unexpectedly led me DexComs continuous glucose monitor. I had resisted CGM for

the same reason Ive resisted having a Blackberry: I avoid most new technologies. But

OmniPods manufacturer, Insulet, for various reasons wanted me to use its insulin pump

in conjunction with CGM, so it paid for three months of supplies. I got another break when

DexCom kindly upgraded me to its seven-day sensor, even before it was available to the

public.So for one who barely knows how to use the television remote, I was now wearing

the latest, most sophisticated diabetes technology in the world. Have I found glycemic

paradise? I wouldnt go that far. But after three weeks, I can say that the OmniPod at

least for me is an incremental but clear improvement over traditional pumps, while

CGM has the potential to transform care. I also believe the real power in these devices is

less physiological than psychological, tools that can shape and manipulate behavior in

unexpected ways. I compare my CGM to a benevolent mother-in-law whose intrusions can

be overbearing but who ultimately has your best interest at heart.

Heres my rule of thumb about diabetes technology: small is better than large; fast is

better than slow; streamlined is better than fragmented. By that measure, the OmniPod has

obvious advantages over traditional insulin pumps, which require filling a cartridge with

insulin, knocking out air bubbles, dropping the cartridge in the pump, activating the piston

rod, attaching and filling the tube, priming, checking for more air bubbles, inserting the

cannula, and connecting the tube to the infusion set. While using conventional pumps, I

tried three or four infusion sets until I found one with relatively little discomfort (some

were outright painful), but my biggest problem centered on occlusion errors, which occur

when the insulin doesnt reach the body, typically when bolusing. This happens, I was told,

with certain body types (lean and muscular, which overstates my own physique, but at

my age, Ill take any compliment I can get). Each occlusion error required me to detach the

tube and reprime the pump, a maddening experience that led me to consider returning to

shots.

The OmniPod is different. As my colleague Kelly Close described in our last diaTribe

issue (www.diatribe.us/issues/4/test-drive.php), the pod is the first tubeless pump.Attached to the body, it delivers insulin via signals from a wireless hand-held Personal

Diabetes Manager (PDM), and the pods are replaced every three days. The infusion process

is automated, quick, and easy. No priming. No air bubbles. No piston rods. The automated

insertion is less painful than a fingerprick, and Ive had no occlusions.

The device still has flaws and is not for everyone. If you forget your PDM before going

to a restaurant, you cant bolus, which means you cant eat. That would be a big drawback

for my 6-year-old diabetic son, whom I fear would lose his PDM with the same zeal that he

loses his baseball caps and mittens. Another problem: You cant take the pod off your body,

and after three days on one site, it begins to feel heavy. Keeping the pod on while playing

continued on page 8

T1

So for one who barely

knows how to use the

television remote, I was

now wearing the latest,

most sophisticated

diabetes technology

in the world.

DexCom STS 7 Continuous

Glucose Monitor Sensor and

Receiver


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certain sports is another challenge; Ive already ripped one pod off the side of my arm just

when taking off a t-shirt. The pod automatically deactivates after 72 hours, regardless of

how much insulin is left. Those shortcomings aside, the simplicity of the product makes it a

superior pump, at least for me.

A friend of mine with diabetes once said to me: I just dont know how I feel. Well, real-

time CGM finally tells us how we feel, at least in terms of blood sugar. The DexCom comes

with an applicator, which injects or inserts the sensor probe beneath the skin. Attached

on top of the skin is the transmitter, which signals a glucose reading every five minutes to

a receiver, and the receiver displays your most recent reading plus trend lines over the past

one, three, and nine hours.

My first few days on the DexCom STS the companys first generation product were

disappointing, because I had so many data gaps and noise. The first night, the alarms

woke me up just to tell me the receiver wasnt receiving any information. Couldnt that

news wait until morning?

Ive had better success with the SEVEN, the companys next generation sensor that can

stay in your body for seven days. The most obvious difference is just that longer duration,

fewer insertions of new sensors. But the insertion itself is less painful, as a smaller needle

is used. Ive also learned to be more forgiving. It appears to take the sensor about 24

hours to get used to its new surroundings, so that first day will have some data gaps andinaccurate readings; but then it becomes more consistent. The receiver also requires daily

maintenance: it must be charged once a day like a cell phone, and it must be calibrated

every 12 hours by doing a fingerstick with a OneTouch meter and then

uploading the meter onto the receiver with a cable.

The DexCom is not approved to replace fingersticks, and its true that at

times there have been 40 or 50 point differences between my DexCom receiver

and my meter reading. So I dont entirely trust the DexCom, but the longer Im

with it, the more faith I have. Its already caught three or four mild nighttime

lows that is, it began vibrating while I was still sleeping. (I believe Ive had

these lows because with the OmniPod, Im no longer losing insulin from air

bubbles in the tube.) It helps to have a tolerant partner with you in bed. Onenight, when my DexCom alarm buzzed and sent a frisson of electricity across

the mattress, my wife lifted her head and said, Youre vibrating.

Of such pillow talk are great marriages made.

The glucose readings provide fresh insights into familiar actions. Ive always known

how easy it is to overtreat a low, but I really understood it when I drank a modest glass of

orange juice and saw the glucose trend line spike from 60 to 183. The sharp decline while

exercising is equally fascinating.

There is something futuristic about the entire enterprise. I see the trend line falling

rapidly. I dont feel anything yet, but I know I have to act. I eat a snack and patiently watch

the receiver. Finally, I see the trend line straighten out, and I want to announce, Glucose

stabilized . . . Beam me up, Scotty!

On another occasion, my blood sugar started to fall when I was stuck in a traffic jam

about the worse time possible, of course, to become hypoglycemic. So I started eating

some Skittles and watching the receiver eating and watching watching and eating

until it finally felt as though I were treating the receiver and not my blood sugar. And who

can blame me? If I went low, my DexCom would buzz, alarm, reprimand, scold, hold me

accountable, and all but lecture me on my failure to take proper precaution. Not the most

pleasant riding mate, but it beats passing out at the wheel.

I will remain skeptical about new technology, and I know that these gadgets in particular

continued on page 9

Heres my rule of

thumb about diabetes

technology: small is

better than large; fast is

better than slow;streamlined is better

than fragmented. By

that measure, the

OmniPod has obvious

advantages over

traditional insulin

pumps.

One night, when my

DexCom alarm buzzed

and sent a frisson of

electricity across themattress, my wife lifted

her head and said,

Youre vibrating. Of

such pillow talk are

great marriages made.

The OmniPod

PHOTO:DANIELBELKIN


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9


dont always work, theyre cumbersome, and theyre expensive; but their ability to change

behavior is their underlying power. For either CGM or insulin pumps to work, patients

must be highly motivated uploading, calculating, calibrating, counting, trouble shooting,

and observing. Always observing. That will exclude some, and perhaps many, diabetics who

dont have the time, interest, or resources to invest in their health.

But if you believe that diabetes is an endless dance to the same old song, we now have

some new partners who can engage, enrapture, and even awe us, long into the night.

dialogue

Jeff HitchcockJeff Hitchcock is the founder of Children with Diabetes, an organization

whose Web site (www.childrenwithdiabetes.com) has become an indispensible source of

information and support for countless families around America and beyond. In the 1990s,

Hitchcock was an Internet pioneer, using this new technology to help patients, but he was

less a visionary than a desperate parent: his daughter had diabetes, and he knew that

other parents had the same questions, fears, and hopes that he had. Hitchcocks company

now sponsors multiple conferences a year the Friends for Life Conference in Orlandojust took place and he plans to expand that part of his business abroad, with the first

international conference taking place in Toronto shortly. In this interview with diaTribes

Jim Hirsch and Kelly Close, he talks about the origins of Children with Diabetes, the

evolution of care, and the history of the organizations conferences.

Jim: When was your daughter Marissa diagnosed with diabetes? What was the hardest

part for her?

Jeff Hitchcock: Marissa was diagnosed when she was just 24 months old, in September

1989. It was a long time ago, and the tools used to manage diabetes then were certainly

crude by todays standards. I guess the biggest challenge we would have faced was trying

to reconcile a toddlers normal eating behaviors with the action of insulin. A smart child

quickly determines that food is a powerful manipulative tool, and if you sit down for dinner

and give X and Y and they say Im not eating, mom and dad get rather anxious.

Jim: Sounds like our house. And does this bring us to how Children With Diabetes came

into being?

Jeff Hitchcock: For many years after she was diagnosed, I worked in the high-tech

software industry. There was one forum in particular on the old CompuServe forums about

diabetes. The postings on there dealt primarily with adults who had diabetes; the number

of people who had online access was very small back then - this is way before the Internet.

There was nothing there to help parents, and absolutely nothing for kids. In the fall of 1994

I was in a company that got access to the Internet. It was clear that this medium was theperfect place to build a support environment for kids who had diabetes. At the time, there

were a couple of sites online. The biggest was called the diabetes knowledge-base run out of

the University of Wisconsin Madison. And again, the content was adults with diabetes, both

type 1 and type 2. Nothing for parents.

As luck would have it, I found myself laid off in the summer of 1995. I called my

Internet service provider and said Im launching this site today; I need a full-time modem

connection. CWD launched the day I got laid off, with a page about Marissa and some

wacky graphics. And I had no real thoughts on what it would become.

continued on page 10

T1

Jeff Hitchcock; founder of

Children with Diabetes


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Kelly: At that point, how many people had you communicated with who had children with

diabetes?

Jeff Hitchcock: None that I recall, to be quite honest. There was nothing there

for families who had kids with diabetes. CWD was sort of my attempt to pass on our

philosophy, which was really to live your life and fit diabetes into it, not the other way

around.

Kelly: How had you developed that philosophy over time, and who influenced you?

Jeff Hitchcock: Well, when Marissa was diagnosed, her endocrinologist at the Childrens

Hospital in D.C. left us with for lack of a better term a very positive diagnosis

experience. We left feeling that we could make a big difference in her life. Those were pretty

much the words he gave to us. And that we shouldnt really worry. I think he had seen

changes in diabetes care beginning with home-glucose monitoring recent studies have

shown that kids diagnosed post home-glucose monitoring have a very different long-term

outcome than kids diagnosed in the 60s, before there was home-glucose monitoring.

So we never had sort of a meltdown, the worlds over, all that kind of stuff. We may

have been very naive, but we just didnt have that.

Jim: Going back to the organization, how did it evolve as you got your feet wet?

Jeff Hitchcock: I made some overtures to companies and was told, The Internet thats

pornography. We dont want to be there. There was no financial support.

I did receive a contract from the JDF, as the JDRF was called at the time, to build and

host their initial website, which was called jdfcure.com. That lasted about 18 months before

they took it in-house.

Back then, the Internet was very new. One of the things that helped us is someone at

Yahoo discovered the site and featured us in a whats new page. Once that happened, our

traffic began to just grow and grow and grow and grow. And the growth has not stopped.

Kelly:What was it like having people writing directly to you?

Jeff Hitchcock: CWD has always been free and anonymous. That has been one of the

things Ive always wanted. In maybe late summer like October-ish I probably got the

first email to Dear Dr. Hitchcock, please tell me about my insulin. About that same time,

an endocrinologist in Kansas City ran a site called Diabetes Monitor, which still exists, and

his Internet service provider was having problems keeping his site up. So I asked him if he

would answer these questions in exchange for me hosting and keeping his site up, and he

agreed. And that served as the foundation for what is now the Ask the Diabetes Team part

of the site.

Jim:Were you still thinking at that point that this could be a business?

Jeff Hitchcock: No. At that time, having been told that no companies wanted to beonline, from a sponsorship perspective, I had no delusions that this was going to be

anything other than a hobby. It remained that until Im not even sure. If you go basically

to late 1999, CWD was not bringing in any financial support to speak of. And it was to the

point where Id almost wanted to just turn it off, because it was so time-consuming.

It was in the fall of 1999, when people were investing a lot in the Internet, and Internet

health in particular, that myself and two other people created Diabetes 123, our company,

and took over running the website from what was the CWD Foundation, which is now a

separate entity. We then promptly watched the NASDAQ crash.

So that was another very scary year. Another go a long time and not get paid kind of thing.

10



I made some overtures

to companies and was

told, The Internet

thats pornography.

We dont want to be

there. There was no

financial support.


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Jim: Did you quit your job?

Jeff Hitchcock: I walked away from what was a very nice job thinking that this was an

easy business. Youve got to kind of go back to the 1999 mentality and what we all thought

was possible. Some of the things we had thought about doing just did not make sense in

retrospect. Online diabetes education is a very expensive endeavor from an infrastructure

perspective, and online sales of diabetes-related products has become something that the

Wal-Marts and the Walgreens manage, not the small boutique companies.But the other thing that happened in 2000 was Laura Billetdeaux, a mom on our parents

list, sent a note out to that list and said, Who wants to come share a vacation in Orlando?

Which became the first official CWD event in June of 2000. Her vacation email invitation

went to the CWD list and 110 families 550 people showed up in Orlando. That was 1995

and the rest is history.

Kelly:Was that the first time that the companies had kind of reached out?

Jeff Hitchcock:We had some financial support from LifeScan. I think that came in about

1997 to fund a section of the site about camps. But that was pretty much it. There were a

couple of little companies, but not enough to pay a mortgage and all that kind of stuff.

When it became clear that it wasnt just five families going to show up at Disney, thatthis was a serious thing, she began calling various diabetes companies. TheraSense stepped

up and was the first company to provide financial support for a CWD event. This was prior

to them actually having a product on the market.

They took a leap of faith in us that this was going to be something that was both

worthwhile and would obviously be beneficial from a corporate perspective. You want

them to feel that. But it was really a big leap of faith in us, that this sort of ragtag group of

Internet people were going to do something.

After spending a day at Sea World and a day at the Magic Kingdom, we asked the

families what they wanted, and the feedback was that people wanted real conference kinds

of stuff. These were parents who had gone to trade shows and conferences and such as part

of their regular work, and they knew what these things could be. From that came the formatfor Friends for Life as we know it now educational sessions, focus groups, a lot of social

activities.

Jim: So, when did CWD in effect become your full-time job?

Jeff Hitchcock: I think sometime in 2002. We finally had enough both online support

and sponsorship at the conferences that I could put aside the separate job. Of course, a

deciding factor was health insurance. We were able to get a policy. Its basically a group

policy with two families, my familys and Lauras. Without that, it would have been very

difficult to do this.

Jim: Switching gears for a moment - what do you think the biggest problems are, either

from a parents or a patients perspective, in diabetes?

Jeff Hitchcock: I dont know that theres a one biggest issue. I think a familys struggle

with suboptimal care; going to clinicians who dont keep up or arent aware of the latest

management tools and strategies, and who impose purely artificial barriers to adoption of

new tools, such as pumps.

Nothing is more frustrating than hearing a parent say, My doctor wont prescribe a

pump until my teenagers blood sugars are perfect. They may not be able to achieve those

goals without that pump those are the kinds of frustrations I see.

Nothing is more

frustrating than hearinga parent say, My doctor

wont prescribe a pump

until my teenagers

blood sugars are

perfect. They may not

be able to achieve those

goals without that pump

those are the kinds of

frustrations I see.

Laura Billetdeaux; Her

vacation email invitation

went to the CWD list and 110families 550 people showed

up in Orlando. That was 1995,

and the rest is history.


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Jim: What do you think are the biggest misconceptions or misperceptions among parents

and patients?

Jeff Hitchcock: Ill give you an example that just came up in the last couple of days on

our forums. A dad posted that his son was newly diagnosed, and he was very anxious about

the long-term effects of type 1. He was just very worried that his son, who is now 16, is

going to suffer what his aunt did 20 years ago.

I think theres this enormous misperception about type 1 versus type 2 in the generalpopulation, and a lack of appreciation for the dramatic advances that medicine has made

in caring for type 1 diabetes in the last 10 or 20 years. I think that people new to this and

who arent left with a good diagnosis experience, leave feeling really anxious and depressed

when I dont think they need to be.

Jim: The first time we met, you said to me that you think complications are a thing of the

past. What did you mean by that?

Jeff Hitchcock:Well, there was a study published in Diabetes Care this year. Basically

they looked at the incidence of nephropathy in kids who were followed for over 20 years.

When they looked at kids who were diagnosed very young say zero to four and

they followed them for 20 or 25 years, zero not one had developed nephropathy.Historically, kidney disease has been a very bad thing if you have type 1 diabetes. And this

study showed very strongly that the world has changed. In kids who are diagnosed older

say the five to nine and 10 to 14 ranges the incidence was just one percent for the five to

nine year olds and just over two percent for the older kids. That is in stark contrast to kids

diagnosed many, many years ago who had very high incidence.

Thats the kind of positive news that families need to hear. Now that comes with the

qualification that you take care of yourself. That you dont just dismiss it. But again, that is

really a very positive message.

Jim: How have the products improved?

Jeff Hitchcock:When we compare glucose monitors from 1989 to today, we go fromthe best meter on the market that took 120 seconds and a drop of blood that would have

made a bricklayer cry, to meters today that are in the three- to five-second range, with sub-

microliter volumes. And integrated data management, or connections to computers to help

identify patterns and improve management strategies.

We look at insulins regular and NPH was the norm, and now both short acting and long

acting analogs have given us incredible dosing options and much better predictability. They

reduce low blood sugar, which has always been the limiting factor on optimizing control.

And insulin pumps, which in 1989 were available but really were not something you

would have put on a two-year-old, are now so small and so lightweight that you can put

them on toddlers. And those tools are what has made that nephropathy study a reality.

These tools make living with diabetes easier. And theyve given patients the opportunity

to basically have complications be something that they dont need to worry about like they

used to.

Kelly: Can you talk about what product out there is doing really well with customers, and

what makes it such a good product. Is it price? Is it great education? Is it that they like the

color?

Jeff Hitchcock: I think the biggest deciding factor on products is customer service. If

you look at insulin pumps, for example, thats a big cash outlay no matter how you cover

it; a lot of supplies every month. And, effectively, youve entered into a relationship with


When we compareglucose monitors from

1989 to today, we go

from the best meter on

the market that took

120 seconds and a drop

of blood that would

have made a bricklayer

cry, to meters today

that are in the three-

to five-second range,

with sub-microliter

volumes.


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a company, because most people buy their supplies from their insulin pump company.

People talk about what happens when things break. Insulin pumps are mechanical devices,

and like any mechanical device, some number are going to break or have a failure. And its

more how the insulin pump company responds to those episodes of crisis because a pump

failure is always a crisis that determines how patients and future customers will view

that company. People dont complain so much about the fact that their pump broke. They

complain about the fact that their pump broke and they didnt get a replacement for three

days because their rep was out of townand the company didnt think they were important

enough to make a delivery that night. Thats where a little investment goes a long way.

Jim:What would you say for meters? Because meters typically dont break down, whats

the deciding factor there for patients?

Jeff Hitchcock: For our audience parents who have kids with diabetes having a

second meter that you dont have to go buy, so that you can leave one at school and have

one at home, is a big thing. So a meter company that will accept a phone call to their

customer service where Mom says, Tommy is in school. Can you send me another meter

this is what he uses so that we dont have to keep schlepping it back and forth? Then

they send it out, and it arrives the next daythats what they should be doing.

Jim:We see more TV advertising for diabetic products than ever before. How would you

assess that trend?

Jeff Hitchcock: There is no question thats changed. And you just have to look at the

television to see all of the commercials for meters. The message adds things that matter

to the patient, not to the clinician: its painless, or it doesnt require coding; or the things

that make a difference to the family. So its very obvious that there is more direct consumer

marketing in the glucose meter space.

Jim:What impact do you think thats actually had on the companies themselves?

Jeff Hitchcock: I have no idea. But I think its a good thing if it raises the awareness that

there are multiple tools. Its not just whatever you left the doctors office with three years

ago. You should be aware that there is innovation. And if it does nothing other than get

someone to go and ask either the pharmacist, or their doctor, or somebody online, whats

out there now, they may find a tool thats better for them. But it does sort of put some

pressure on companies to continue to innovate and come out with new models and stuff.

Kelly:Your conference this year in Orlando was absolutely fantastic. So much incredible

learning and meeting so many increidbly interesting people. Year after year, more and

more families come to your Friends for Life Conference. What is most drawing them to

Orlando?

Jeff Hitchcock: One very important thing is that families who come and have a great

experience want to come again, because they see that its made an enormous differencein their childrens lives and in their own. At the end of each conference, the teens are just

sobbing as they part. Its mystifying. But theyre literally just bawling their eyes out because

theyre not going to see the friends theyve met until the next conference.

And thanks to cell phones and email, theyre able to communicate throughout the year.

But these kids from different parts of the country and, in some places, different parts of the

world have become friends in a very powerful way. They share something with these other

kids with diabetes that they just dont share with their peers at home. And the families, the

moms and the dads, have the same kind of experience.

a pump failure is

always a crisis that

determines how patients

and future customers

will view that company.

People dont complain

so much about the fact

that their pump broke.

They complain about

the fact that their pump

broke and they didnt get

a replacement for three

days because their rep

was out of town...and

the company didnt think

they were important

enough to make a

delivery that night.


14/24

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So we have this growing body of families who come. When they go back to their

communities and meet in their support groups, they talk about what it was like. And word

spreads, basically. We are able to bring these world-class researchers and clinicians to come

and meet with the families and talk to them about daily care strategies and whats coming

in a very relaxed atmosphere. And thats just an incredible opportunity for everyone, me

included.

Jim: On a related note, whats been most satisfying about what you have built over these years?

Jeff Hitchcock: When I sit here and look online at the traffic statistics, theyve gone

up consistently. But those are just numbers, and its difficult to have an emotional

experience with that pool of data. But when Im standing onstage in front of 1,500 people

and watching a slideshow of our kids over the years, growing up healthy and happy, and

interacting at conferences and the like, that is very rewarding. It cant not be. So while the

website, obviously, has a chance to reach many more people than our conferences can, the

conferences have become the heart and soul of what we do.

Jim:What frustrates you or concerns you the most about diabetes today? Youve spoken

about how much things have improved, but there must be things that still get you

frustrated.

Jeff Hitchcock: I think a very significant, unaddressed problem is access to these tools.

And that gets to how we fund health care in the US. And, at some point and I dont

know how soon as a nation, I think we have to realize that access to what we know to be

good health care practices, whether its in diabetes or cardiac health or anything, makes a

difference for us as a nation, both economically and otherwise.

Its foolish in my mind that companies like General Motors have to worry as much about

health insurance as they do about the quality and features of their automobiles. Those

companies should be building cars or computers or whatever they do. And, as a nation, I think

we need to step up and realize that healthcare matters as a nation, and were just not there yet.

Jim: Do you envision ways of expanding what youve already got, or are you kind of gettingready to wrap things up and retire?

Jeff Hitchcock: I cant retire until we have scheduled the Children Who Used to Have

Diabetes Conference. Were not there yet, though I do look forward to that.

14

I cant retire until we

have scheduled the

Children Who Used

to Have Diabetes

Conference. Were not

there yet, though I do

look forward to that.

Jeffs daughter Marissa (2nd

from right) with children at the

CWD conference. Marissa is an

inspiration indeed she was an

active staff member at the 2007

conference and is in the midst of

study to be a CDE.

PHOTO:WWW.CHILDRENWITHDIABETES.COM


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logbook

A Challenge to the Acting Surgeon General

By James S. Hirsch

He sees no patients. He doesnt submit insurance claims. And he

doesnt run any clinic or hospital. But the U.S. Surgeon General isthe most important doctor in America.

Sometimes called Americas top doc, the surgeon general is appointed

by the president, and his or her job is to promote the health of the nation

through education and to advise the president on health care policy. Some

surgeon generals have been controversial while others quite influential: Dr. C. Everett

Koop, who held the post from 1982 to 1989, used the bully pulpit to help change the

countrys policies on tobacco and AIDs.

With diabetes now making a legitimate claim as the countrys number one public

health threat by the governments own estimate, one in three Americans born in this

century will develop the disease we would hope that the surgeon general would make

diabetes a national priority. But thats not the case. The surgeon generals web site (www.

surgeongeneral.gov/index) identifies five public health priorities: disease prevention,

eliminating health disparities, public health preparedness, improving health literacy, and

organ donation.

All of these intersect diabetes but do not focus full attention on the disease itself and do

not send any clarion call to action.

A Diabetic Patient in High Places

Which might be a little odd, because since August of last year, the acting surgeon general

has been Rear Admiral Kenneth P. Moritsugu, who was diagnosed with diabetes seven

years ago at age 55. Prior to his current appointment, he had been deputy surgeon general

since 1998 (in 2002, he briefly served as acting surgeon general).

In many ways, Dr. Moritsugu is an inspiration, showing that diabetes has not impairedhis ability to work at the highest levels of government. He has also had to overcome

stunning personal tragedies that make his professional accomplishments stand out even

more.

He was recently the keynote speaker at the Friends for Life Conference in Orlando for

the Children with Diabetes organization. Standing in his white gold-braided navy uniform,

his chest bedecked with ribbons, he slipped his Animas insulin pump out of his pocket to

show the children that he was one of them.

I am also a patient, he said, stressing that everyone including himself needs to

better understand health literacy.

But does Dr. Moritsugus employer the federal government understand the scope

of the diabetes epidemic? Consider the governments spending for medical researchfor diabetes: between 1980 and 2006, the NIH budget for the disease increased by 240

percent, to $1.1 billion, but its total expenditures grew by 261 percent. So the percentage

given to diabetes slightly declined even as the number of diabetics had doubled. (Even

more sobering: the NIH in 2004 spent $68 for each diabetic, compared to $16,936 for each

patient with the West Nile virus.)

Blame It on Congress

In an interview with me, Dr. Moritsugu blamed the funding shortfall on Congress. We can

only administer those programs for which we have authority, he said, and we can only


I am also a patient, he

(Dr. Moritsugu) said,

stressing that everyone

including himself needs

to better understand

health literacy.

Acting Surgeon General Ken

Moritsugu; Americas top doc


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distribute those funds which have been legislatively appropriated to us . . . As a patient, I

see that the federal government is doing a good job with the funding that it has.

If anything, Dr. Moritsugu said, diabetic patients should look less to the federal

government for help and more to themselves. From my experience of 36, 37 years as a

career officer in public health services, I have seen programs come and go, and the biggest

mistake is if everything is leveraged on federal funding, as opposed to a partnership on the

federal level, the state level, the community level, private organizations, and foundations.

From that perspective, it is less us who have the power to affect the federal component of

funding for research than you, meaning the constituency who actually has better access to

the ears of those who make the appropriations.

My first reaction to those words was: ugh, what a cop out. Yes, I can write a letter to

my congressman, but I dont have the megaphone that a president has, or a senator, or an

acting surgeon general. Why are none of them doing what President Franklin Roosevelt did

for polio make its defeat a real priority?

Dr. Moritsugu said the emphasis by the surgeon generals office on disease prevention

is very much tied to diabetes. (The Web site identifies diabetes, along with heart disease

and many forms of cancer, as examples of preventable chronic diseases that kill 70

percent of Americans each year.) The first priority is prevention, he said. I think

overweight and obesity will put this smack dab in the middle of the radar screen. Hedescribes the complications of weight gain and obesity heart disease, kidney failure, etc.

as the domino effect.

Connecting the Dots

Prevention is a laudable strategy to curb the type 2 epidemic, but is diabetes per se just

another domino? Of course not, its the entire game board, and Dr. Moritsugu said that

he understands the vast challenge before us: changing lifestyles, improving health care

delivery, and increasing biomedical research. He calls the challenge connecting the dots.

Many of us want to do good things for the health of America, but what we do is not

really integrated into an overall strategy, he said. We need to look at overweight and

obesity and diabetes as not simply a health issue but a dietary issue thats the Departmentof Agriculture. Its a Housing and Urban Development issue. Its a Transportation issue.

Its an Education issue. Its a Commerce issue. You say, Eat well, but in some of our

communities there is no supermarket within a reasonable distance, so we have to bring

commerce into the neighborhood and we have to help people help themselves do the right

thing. . . This is a long way of saying, Connect the dots.

But Dr. Moritsugus integrated strategy begs the larger question Who will connect the

dots? Who will unite these disparate entities, across all levels of government and all walks

of life, to fight a common foe?

Looking for a Leader

Perhaps the best qualified person in America is Dr. Moritsugu himself. While he lacks the

charisma of a Colin Powell, the resources of a Bill Gates, or the power of the president, he

has a remarkable personal story of triumph and heartbreak that commands attention.

Born in Honolulu of Japanese descent, he has both a medical degree and a masters degree

in public health. He entered the Public Health Service in 1968 and has held numerous

positions, including medical director of federal prisons, and has won a slew of honors,

including the Surgeon Generals Medallion. (I dont know what that is, but it sounds

impressive.)

Resume aside, what distinguishes Dr. Moritsugu is family tragedy: he lost his wife in

an auto accident in 1992, and then his daughter was killed four years later, at age 22, in a



We need an integrated

strategy that looks at

overweight, obesity, and

diabetes as not simply a

health issue but a dietary

issue we should

involve the Departments

of Agriculture, Housing

and Urban Development

Transportation, Education

and even Commerce.

You say, Eat well,but in some of our

communities there is

no supermarket within a

reasonable distance


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separate car accident. Dr. Moritsugu has used these tragedies to promote organ donation.

Both his wife and his daughter were donors, and he found comfort in knowing their organs

saved others. (A retired policeman received his wifes heart.) Organ donation stands as one

of the health priorities of the surgeon generals office.

Dr. Moritsugu, who has remarried and has two daughters, will return to his position as

deputy surgeon general once the current nominee is approved. Asked about the leadership

vacuum in diabetes, Dr. Moritsugu told me: Waiting is passive, instead of what I know is

part of the fabric of America, which is that people come together and raise their voices and

say, Hey, pay attention to that issue, and here is the science, and here is the evidence, and

here is the emotion.

But what role should you play?

He paused before answering, then looked me in the eye. I have engaged in the

challenge, he said. I have engaged in the challenge with the Office of the Secretary (for

Health and Human Services). I have engaged in the challenge with our former surgeon

general, and there is another nominee, and I have engaged him.

But how many people in America know about Kenneth Moritsugu about his life story,

about his experiences, and about his commitment to diabetes?

Basically, Im holding myself out to the department and saying, Use me. I am the one

who has the disease. It is very personal as well professional.With a glint in his eye, he thanked me for pressing the issue.

I hear your challenge, he said, and I am willing to rise to it.

learning curve

The Mediterranean Diet

By Daniel Trecroci

The Mediterranean Diet Makes Sense of the French Paradox

It was first publicized in 1945, but it took more than 50 years to get its name the

Mediterranean Diet. By the 1990s, researchers noticed that people living in Mediterraneancountries consumed high amounts of fat, but unlike their fat-consuming counterparts in the

U.S., they were at less risk of heart disease.

This is sometimes referred to as the French paradox, but it really isnt a paradox at all:

Americans consume higher amounts of saturated fats, while in the Mediterranean world,

monounsaturated fats are more likely to be consumed.

But fats alone are not responsible. What really puts the gusto in the Mediterranean diet

what has drawn so much attention is the wine.

Its the Type of Fat That Counts

But dont overdo the happy hours. Moderation, of course, is paramount, and there is more

research data on monosaturated fats than on Merlot.In the Mediterranean diet, the main fat is olive oil, with a very high content in

monounsaturated fatty acids and more than 200 microcomponentsmany of which exert

beneficial properties to health, Dr. Antonia Trichopoulou, a researcher at the Department

of Hygiene and Epidemiology at the University of Athens Medical School in Athens, Greece,

told diaTribe.

Dr, Trichopoulou, as well as researchers from Harvard School of Public Health,

published a study in the New England Journal of Medicine (July 26, 2003) that found that

a greater adherence to the Mediterranean Diet is associated with a significant reduction

in total death. Dr. Trichopoulou told diaTribe that, combined with physical activity and

17

PHOTO:MARKYARCHOAN


T1/2


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weight control, the Mediterranean diet is ideal for a person with type 2 diabetes. One of his

more recent studies in the Journal of Internal Medicine (June 2006) found that increased

consumption of eggs and saturated fats was associated with significant increase of death in

people with diabetes while monounsaturated fats were found to be preferable for diabetic

persons.

The Mediterranean Diet Explained

According to the American Heart Association (AHA), the common Mediterranean Diet

has these characteristics:

A high consumption of fruits, vegetables, bread and other cereals, potatoes, beans,

nuts and seeds

Olive oilan important monounsaturated fat sourceused for cooking and dressings

Dairy products, fish and poultry that are consumed in low to moderate amounts

A minimal consumption of red meat

Eggs are consumed zero to four times a week

Low to moderate consumption of full-fat cheese and yogurt

Moderate consumption of wine, usually with meals

Reliance on local, seasonal, fresh produce

An active lifestyleMore than half the fat calories in a Mediterranean diet come from monounsaturated

fats (mainly from olive oil), says the AHA. Monounsaturated fat doesnt raise blood

cholesterol levels the way saturated fat does.

Data Everywhere Support the Mediterranean Diet

According to data from the Lyon Diet Heart Studya randomized, controlled trial

designed to test the efficacy of a Mediterranean-type diet in people who have had a heart

attackpatients following the Mediterranean-style diet had a 50 to 70 percent lower risk of

recurrent heart disease.

A study in the Archives of Internal Medicine (June 11, 2007) found that individuals at

high cardiovascular risk who adopted one of two traditional Mediterranean diet (TMD)patterns TMD + virgin olive oil or TMD + nutsshowed significant reductions in cellular

lipid levels and LDL oxidation.

In another study, in the American Journal of Clinical Nutrition (August 2006),

data suggested that of the several components of the Mediterranean diet, alcohol, nuts

and whole grains showed the strongest association with adiponectin concentrations in

women with diabetes. Adiponectin is a protein hormone secreted from fat tissue into

the bloodstream that changes a number of metabolic processesamong them, glucose

regulation. Researchers discovered that, Close adherence to a Mediterranean-type diet is

associated with higher adiponectin concentrations.

Talk with Your Healthcare Provider

As with any diet, be sure to talk with your healthcare provider if you are thinking about

starting this one.

18

Americans consume

higher amounts of

saturated fats, while

in the Mediterranean

world, monounsaturated

fats are more likely to

be consumed What

really puts the gusto in

the Mediterranean diet

what has drawn so

much attention is

the wine.


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profile

A Coachs Creed: Balancing Work and Life for theChronically Ill

By Amy Tenderich

In 1980, Rosalind Joffe was on the verge of landing her dream job with a multimediaproduction company when she unexpectedly developed multiple sclerosis (MS). Her

immediate ambition was derailed, but not her life. She bore two healthy daughters and

became a communications professor at Boston University.

Then in 1993, she was diagnosed with ulcerative colitis, which left her weak and

sometimes unable to walk. Suddenly, any job requiring her presence on a regular basis was

too much. She quit her teaching position but did not want her career to end.

I still wanted to work, but I had to find a whole new career that would be flexible

no matter what my health was like, says Joffe, 48, who lives in the Boston suburb of

Newton. Lots of people thought I was crazy. Theres no precedent for people who are sick

continuing to work.

Working from home, she started a consulting/executive coaching business, but thatevolved into something even more specialized: a business that helps others with a chronic

illness develop their own balance between work and life.

Four years ago, Joffe launched CIcoach.com, offering individual and group consulting.

She focuses on living with a chronic illness and the specific workplace issues it presents.

To date, she has helped over 60 people diagnosed with an array of illnesses cancer,

MS, lupus, Crohns disease, and of course, diabetes explore their own altered capabilities

and work/life priorities.

In reality, anyone with chronic illness is dealing with essentially the same stuff, Joffe

says. Fatigue, frustration, guilt over spending time away from the family. But as long as we

dont talk about it to our bosses or others, nothing will be done about the problems people

encounter with chronic illness until its too late, and the person goes out on disability.

While a chronic disease used to be considered an aberration, those days are long gone.

More than 125 million Americans and 40% of Americans in the workforce now live with

at least one chronic health condition, according to the think tank Partnership for Solutions

at Johns Hopkins University. More than 60 million Americans have potentially life-

threatening conditions such as heart disease, hypertension, cancer, arthritis, and diabetes,

and nearly 10 million American people continue to work despite a disability.

Helping Clients Connect the Dots

Joffe offers an approach thats a little like What Color is Your Parachute? for the

chronically ill: through a series of phone calls and visualization exercises, she helps

clients identify what is possible and agreeable to them in the workplace.

Each time we talked, Rosalind was able to connect the dots on a lot of things I wassaying about what was important for me, says Mark E. in Minneapolis, a client with MS

who works for a large healthcare software company. [Like other clients interviewed for this

story, Mark asked that his last name not be disclosed in part because he wants to control

who knows about his illness.] The big aha was that being on the fast track to a high-level

management position wasnt really a good fit for me right now. What I needed was more

flexibility and less stress.

Some common missteps occur when people try to ignore their illness altogether, or

simply attempt to charge through it and perform as if their health didnt matter. In


T1/2

Life balance expert

Rosalind Joffe

Lots of people thought

I was crazy. Theres no

precedent for people

who are sick continuing

to work.


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www.diaTribe.us


response, Joffe has developed guidelines on how to discuss your illness in the workplace

and any special needs you may have.

After working with Joffe for about six months, Mark E. was able to scale back from a

national sales position requiring a 14-hour workday, including a two-hour commute, plus

his responsibility for a dozen employees, to a position in business development where he

works from home. With Joffes help, he was able to do this without losing face at work or

compromising his own pride.

She helped me present myself as a still-valuable employee, who still wants to work

hard, still wants a challenge, and is still loyal to the company. I just need to do things

differently right now, he says.

Clients say the magic that sets Joffe apart from other career coaches is her natural empathy

and her personal experience working with a chronic illness in the corporate world. Other

coaches dont get the aspects of being ill, and how it affects your life and family, Mark E. says.

Jackie V., a 23-year-old school teacher in Connecticut diagnosed with MS fresh out of

college, was plagued by a sense of inadequacy. I was so exhausted all the time, but I didnt

want to ask for accommodations at work. The coaching helped me see that asking for help

is not a sign of weakness. Im not giving in. Its healthier to remain in work and go about

your life rather than stay at home hiding.

Her talks with Joffe focused about 60% on work issues and 40% on personal matterssuch as pivotal relationships and stress at home. Taking Joffes advice to approach her

boss with an upbeat attitude and specific compromises in mind, Jackie was pleasantly

surprised by her colleagues reaction. She now works four hours a day instead of eight,

and says she feels much healthier both emotionally and physically.

Joffe has had similar results with her diabetic patients. In one instance, a woman was

diagnosed following her third pregnancy. She was briefly in diabetic coma, and her husband

had begged her to stop working. She was confused and emotional.

She was basically ignoring her diabetes, and her husband thought stopping work was

the solution, Joffe says. Through our sessions, she came to the realization that she loved

her job. She decided to cut back temporarily, to give herself time to acclimate to living with

the disease, but she did not want to stop working permanently. This client recently wentback to work full-time, now confident that she can balance her career with caring for her

health and her family.

Spreading the Word

For many clients, a core issue is disclosure. Who should they tell, and how? According to

Joffe, very few people struggling at work due to chronic illness engage the Human Resources

(HR) Department. HR simply isnt trusted, since people assume its members will always have

the companys interests in mind, and they may not keep the information confidential.

The thinking is, if they know about your condition and they think youre a problem,

theyll be angling to get rid of you, Joffe says.

Client Steve D., in his 30s and also living with MS, was grappling with the disclosure

issue for two reasons. First, having a secret is very isolating, he says. Secondly, although

his position at a biotech research company in Seattle requires mostly brain work, the

job description also called for a fair amount of work in a laboratory, which meant hours of

standing on his weak legs. His father pointed him to CICoach for help.

First we talked about the legal issues what are my rights? And then Rosalind helped

me put a positive spin on things, identifying what I can do for the company to still be of

value, rather than talking about what I cant do. Basically, its doing a little bit of sales for

yourself, Steve says.

Joffe suggested limiting disclosure on a need-to-know basis, identifying the critical

20

In reality, anyone with

a chronic illness is

dealing with essentially

the same stuff

fatigue, frustration, guilt

over spending time away

from the family Some

common missteps

occur when people try

to ignore their illness

altogether, or simply

attempt to charge

through it and perform

as if their health didnt

matter.


21/24

www.diaTribe.us


people, and then discussing it with them in the right light. The strategy worked, as

Steves boss was very responsive to his request for an altered schedule. Joffe emphasizes

to her clients the importance of finding a boss who is sympathetic and flexible though, of

course, many workers dont have that luxury.

While Joffe instructs her clients to carefully disclose information about their health,

its also important that enough people know about any illness in case of an emergency.

Anyone with an invisible and chronic illness faces these issues, she says. But as long as

its continually swept under the rug, were kind of living in silos.

Ultimately, Joffe says, patients have to be their own best advocate. If we can band

together, we can have a voice, which would be really helpful in educating employers,

managers, and colleagues so the workplace can be a more supportive place, she says.

Theres power in numbers and a lot of comfort around the sense that youre not alone.

Learn more about chronic illness in the workplace at:

www.cicoach.com

www.keepworkinggirlfriend.com (Rosalind Joffes co-authored blog)

www.partnershipforsolutions.org

http://www.advocacyforpatients.org/

Amy Tenderich is author of the popular web log www.diabetesmine.com, and

coauthor of the valuable book, Know Your Numbers, Outlive Your Diabetes.

trial watch

Anti-CD3 mAb Treatment of Recent Onset Type 1 Diabetes

This study will test whether a single 14-course treatment with an anti-CD3

monoclonal antibody will prevent the loss of insulin secretion capacity in type 1s who have

been diagnosed for a duration of 4-12 months. Previous studies have shown that treatment

with CD3 antibodies can preserve residual beta-cell function in type 1s. This is a JDRF/Yale

sponsored phase 2 trial started in September 2006 and researchers are looking to enroll

60 participants at the two study sites; Yale University, New Haven (CT) and University

of California, San Francisco. Check out the website at: http://clinicaltrial.gov/ct/show/

NCT00378508?order=3.

Diabetes Technology Study of Real-Time Glucose Alerts in the Team

Management of Diabetes

Have you ever had a particularly good week of blood glucose results that you could not wait

to share with your doctor or educator? If so, this Diabetech-sponsored study has your name

all over it. It will use a special glucose meter to send wireless alerts to a team of healthcare

providers of your choice. This will give them a chance to review your glycemic levels before

your next appointment. We believe the possible advantages to this are two-fold. Your

provider will be better informed when you next see him/her and they would spend less time

when youre in the office looking at logbooks/glucose meters and more time looking at you!Who knows what applications could come parents could even receive a blood sugar text

message from their child at school during a hypoglycemic event if the technology takes

off. We believe ultimately its more about self management than physician management

(the truth is they probably dont all have time to look through mountains of numbers

its probably better for you to look at the key ones!) But all these trials will be great for

researchers to learn more on the technology so were all in favor. The research team is

looking for 1000 participants and they expect to complete the study in December 2007.

Check it out on the web at: http://clinicaltrials.gov/ct/show/NCT00322478;jsessionid=66

016FA616632B9A9142F556554019F8?order=4.

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what were reading

GLP is the 1 For Me: Recent Literature Shows Promising New

Formulations of GLP-1 on the Horizon

Byetta has been the first of a relatively new class of diabetes drugs called incretin

mimetics or GLP-1 analogs. GLP-1 is a gastrointestinal hormone, or incretin, which

is released in the body during meals to enhance the insulin response to the new glucoseload. We discovered several years ago that GLP-1 does not merely help the insulin release

but actually caused about 70% of it. Without enough GLP-1 in the body, ins

diatribe - research and product news for people with diabetes - issue #5

Documents