goingf rwar - friends with diabetes · to cleaning those mounds of seforim or search-ing for...

GoinGF rWarDFriends With diabetes

Preparing for Pesach

Against the Shadows

Starring Byetta and Symlin

6

19

27

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F.W.D. is under the rabbinical supervision of Rabbi M. M. Weismandl shlit”a of Nitra–Monsey, endorsed by many other renowned Rabbonim, and by leading medi-cal professionals.

the information in this publication is meant to be used in conjunction with, and under the guidance of, your health care professional. it is nOt meant to diagnose or treat medi-cal conditions, nor as advice or prescriptions. it is provided for educational purposes only. in the event that you use the information without your doctor’s approval, you are prescribing for yourself, which is your constitutional right, but F.W.d. and the authors of this publication assume no responsibility. We strongly advise that you inform your doc-tor of any changes you wish to make.

Please consult your physician for medical questions, and your Rav (Rabbi) for halachic (Jewish law) decisions.

FWD does not assume responsibility for the kashrus of any products advertised in these pages.

31 Herrick Ave. Unit B Spring Valley, NY 10977(845) 352-7532 Fax: (845) 573-9276 [email protected] www.FriendsWithDiabetes.org

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Spring 5767 | � | Going ForWarD

A Time to Reflect

As we’re making steady strides ForWarD, I take a moment to pause long enough to thank those who make our success possible. First and foremost, I thank Hashem for guiding us every step of the way. I pray for continued siyata dishmaya to be able to continue with our bi-monthly publication and our dozens of annual functions.

I also wish to thank our sponsors and advertisers, without whom this full-color informative booklet would have remained a dream. We urge our readers to take advantage of what our advertisers have to offer, and upon doing so, please mention that you saw their ad in the Going ForWarD publication. We would also appreciate to hear of your experiences, whether positive or otherwise, with any new products or services.

Special appreciation is due to those who sent us the voluntary annual membership fee to help us grow and reach out to more people. If all the people on our mailing list would send even the minimum suggested membership fee, all of the printing expenses of this publication would have been covered. I hope those who think that their small donation won’t make a difference will reconsider.

I thank those who took the time to share their feelings about the events we coordinated, about this publication, and about their personal trials and triumphs. These letters are the road signs that help us go ForWarD in the right direction.

I wish to express my profound appreciation to all the volunteers who help out during the functions and events. The success of these gatherings is to their credit. May Hashem bless you for your kindness and fulfill your innermost desires.

Special thanks to our editor who gives her talented input and transforms my notes into beautiful articles, working into the wee hours of the morning. May Hashem grant her good health and much nachas.

And finally, a resounding “thank you” to my devoted family, my dear parents, wife and children, who stand by my side and help me with this never-ending adventure…

*We hope you enjoy strolling through the pages of this issue, reading about the recent events

and learning about some new diabetes-control options. The article on Byetta and Symlin is a must-read for people with type I or type II diabetes. While Byetta is becoming increasingly more popular for people with type II diabetes, Symlin could benefit many more people than those who currently use it.

Rejoice with the simchas featured in our Mazel Tov Corner, and remember to share your simchas, too. The inspirational message in Against the Shadows provides the food for thought that can give us a gentle push ForWarD in our personal struggles.

jnau raf dj ,frcc,

Rabbi Hirsch Meisels

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Going ForWarD | 6 | Spring 5767

Practical tidbits on The Four Cups heard over the phone

In a well-appointed office in Monsey, Rabbi Meisels is heavily engrossed in

Pesach preparations. No, we’re not referring to cleaning those mounds of seforim or search-

ing for runaway crumbs from last month’s shabbaton (although those have to

be done as well). We mean pa-tiently and carefully responding

to the almost endless chain of callers seeking clari-

fication, assurance and assistance re-

garding the seder night. Many calls revolve around

the required four cups of wine or

grape juice.

RRRRing… RRRRing…

Mr. C. “i’m thinking about the seder this year and wondering…would it be okay for me to drink grape juice for all four cups?”

Rabbi Meisels “Four cups of grape juice or a sweet wine, on top of all the matzah and other carbohydrates consumed at the seder,

might be too much for almost anybody to handle. You would probably find yourself with very unpredictable blood sugars afterwards. Would a dry wine, which has a much lower sugar content, work for you? You can even add some artificial kosher l’pesach sweetener!”

Spring 5767 | 7 | Going ForWarD

Mr. C. “that’s actually what i tried last year, but the wine made me so drowsy, i could hardly concentrate on the haggadah after downing the last cup!”

Rabbi Meisels “in that case, please review our Going ForWard Pesach publication for the exact amount of wine that needs to be consumed according to halacha. You may be able to get by with less than 2 ounces for each cup. i would also suggest-”

Mr. C. “sorry for interrupting; did you mention the Pesach publica-tion? that should be required reading for every Jew with diabe-tes! i actually put it away last year together with my collection of haggadahs and i’ll certainly read it again before this year’s seder!”

Rabbi Meisels “thank you! and let me continue what i was about to suggest. When you do unpack the Pesach journal, i’d suggest you check out the wines listed there. if you would be fine with the alcohol content, i would recommend a real dry, zero-carb wine like Cabernet, Merlot, Zinfandel (red wines), or Chardonnay and sauvignon blanc (white wines). but what you prob-ably need is a more balanced wine, with somewhat more carbohy-drates but a lower alcohol content. (Generally, the lower alcohol wines contain more sugar.) a wine of choice might be red Chablis, with only � grams of carbohydrates

in half a cup and an alcohol content of 8%. (You may already know that drink-ing a smaller amount of a high alcohol wine is equivalent to drinking more of a lower alco-hol wine.)

Mr. C. “i will certainly look into this option. You know, the Pesach publication we keep on mentioning also had an extensive discussion about mix-ing wine and grape juice with water. is this something for me to consider?”

Rabbi Meisels “diluting the wine or grape juice with water is an idea that each individual will have to discuss with his own rav. the rav we consulted ruled that it is permissible to dilute dark juices by a third and lighter juices by a quarter, if the manufacturer didn‘t do so yet.”

Mr. C. “One of my friends suggest-ed adding ice cubes to the wine as a way of lessening its carbohydrate content in a tasteful fashion.”

Rabbi Meisels “this idea sounds questionable at best, since the ice will not mix with the juice. it will only serve to subtract from the fullness of the cup, rendering the shiur incomplete.”

Mr. C. “thank you so much, rabbi, for your time and valuable infor-


mation! now i feel much more pre-pared for the seder!”

RRRRing…RRRRing…

Mrs. K. “i would like some advice for a somewhat no-win situation. On the one hand, tight blood sugar control is very important to me right now and i cannot afford to indulge in four cups of grape juice. but at the same time, special considerations do not allow me to consume alcohol. What can you suggest?”

Rabbi Meisels “this is a predica-ment that would have to be discussed with your medi-cal team. also, speak to your rav about using a very small shiur for the four cups, mixing the juice with wa-ter, or perhaps even substitut-ing the wine or grape juice with a differ-ent beverage altogether (one that has been desig-nated by our sages as “chamar medinah”, a national beverage). a rav who has diabetes himself told me he drinks diet Coke instead of wine at the seder.”

RRRRing…RRRRing…

Mr. W. “i’m sure you remember me! My eight-year-old son was diagnosed with diabetes several months ago, and you spent many hours advising and encouraging us…now that Pesach is approach-ing, we realize that drinking four cups of grape juice may be prob-lematic. but when we suggested to our son that he drink less grape juice than his siblings at the seder, he became very upset. he is b”h doing so well, but hates feeling “different” than his peers.”

Rabbi Meisels “Your concern is understand-

able, and so is your son’s reaction. it is our philosophy

at FWd that children could and should lead completely nor-mal lives with diabetes. did you discuss this dilemma with your son’s dia-betes team? as a once-annual oc-casion, the four cups of grape

juice, spread over several hours, could

most likely be incorporated into his treatment plan. and remember that it is ‘sometimes’ worth sacri-ficing perfect blood sugar control

Reminder: Please consult your

physician for medical questions, and

your Rav (Rabbi) for Halachic (Jewish

law) decisions!

Our Pesach journal is a compre-hensive guide to matzah, wine and more for every family with diabetes, and is avail-able directly from Friends With Diabetes.

in order to cultivate a healthy at-titude in your son.”

Mr. W “Your advice makes a lot of sense! i’ve heard that Kedem’s ‘Light’ lower carb concord grape juice contains just 6 grams of car-bohydrates in a half-cup serving (12 grams in a full 8-ounce cup, and the white one has 17 grams per cup). remarkably, Kedem man-aged to lower the carb content of the juice without lowering its taste! Can i dilute it further?

Rabbi Meisels “this juice already contains ��% water, so no addi-tional water may be added, unless you receive specific permission from your rav.”

We wish all our readers a very beautiful and kosher Pesach! May we merit this year to drink the fifth cup, “V’haveisi”, in Yerushalayim, with the coming of Moshiach tzidkeinu!



Teves 5767 – Dec. ‘06

Glowing Stars

stars can do much more than twinkle in the night sky. they can play games, share life experiences, giggle together and have a great time.

about twenty shin-ing stars gathered for an unforgettable, nothing-was-ever-like-this shabbaton in Monsey to expe-rience a weekend full of growth and discovery. the girls, ages 12-18, ranged from many differ-ent backgrounds and communities. but just like stars in the sky come in all dimensions and sizes, yet create breathtaking con-stellations with perfect harmony, so too, the girls enjoyed each oth-er’s company immensely despite their differences. the atmosphere was truly second to none, full of warmth, friendship and trust.

“We all got to know each other, and it was a good thing we did,”

one participant commented, “be-cause during shalosh seudos we were actually quizzed about our ‘buddies.’ it was fun to see how well we got acquainted.”

rabbi Meisels welcomed the girls, and with a beautiful vort on the Parsha, he brought home the

power of achdus, friendship and togetherness.

the program started off with an informative lecture by a renowned diabetes educator from animas, who shared new discoveries and updates. afterwards, the girls played several games, followed by an inspiring and moving lecture by


rabbi Pinchus Jung, Menahel Ruch-ni of bais rachel school in Monsey. rabbi Jung stressed the fact that aside from the responsibilities urhcjk ost ihc and ouenk ost

ihc (between man and hashem and between man and his fellow man), we each have a responsibil-ity towards ourselves. instead of blaming ex-ternal factors, such as a problem or situation, we should become masters over our thoughts and actions and grow from life’s challenges.

the Friday night seuda was fes-tively prepared and absolutely delicious. dur-ing the meal, one of the girls addressed her fellow stars, making their eyes “twinkle.”

after the meal, the girls partici-pated in an informal panel discus-sion which addressed various dia-betes topics. “there was nothing like sharing experiences, asking questions and troubleshooting problems together,” one of the participants said. the atmosphere was unbelievably pleasant, with the girls stifling yawns until well into the night. they weren’t going to miss a minute of it, regardless of the time!

after a lavish breakfast-kiddush on shabbos morning, the girls were addressed by Mrs. Weingar-ten, a noted mechaneches with a warm personality. the girls sat spellbound as Mrs. Weingarten encouraged them to take credit for good effort, regardless of the

accomplishments. “i didn’t accomplish any-thing is an expression of today’s mentality when a person can’t show any tangible results for his work,” she pointed

out. “Change this mindset. if you spend time tak-ing care of your-self, although not always suc-ceeding, the effort was still worthwhile.”

during the sumptuous seuda, an-other girl addressed her friends with words from the heart. after the meal, the participants schmoozed and socialized with each other for a while before gathering for some more games that kept everyone on their toes, or rather, on top of each other… the room was filled with excitement and laughter, as the girls had the time of their lives.

shalosh seudas once again “starred” one of the participants. With shabbos ending early eve-ning, the girls could hardly get

And until the long-awaited

redemption will dawn, the stars shine brightly in the night sky…


enough before it was time for havdalah.

rabbi Jung then addressed the older girls, discussing the power of prayer and inspiring them to maintain a strong connection with hashem through tefillah. at the same time the diabetes educator addressed the younger girls, and discussed issues relevant to them.

With “shining” smiles, the girls posed for pictures, signed au-tographs and said their good-byes, while promising to keep in touch.

and until the long-awaited re-demption will dawn, the stars shine brightly in the night

sky…

Everything I will ex-press with pen and paper about the Shabbaton will be understated. There is

nothing more uplifting

than sharing my challenge

with someone who strug-gles with the same thing.

It’s beyond imagination

what such a Shabbos holds

until you experience it

yourself…

The entire Shabbos was like a dream – a fantasy. I had so much fun and felt so at ease, I couldn’t compare the feeling to anything I ever experienced before!

I received various insights, ideas and suggestions from my friends at the Shabba-ton, But most importantly, I received support!

The Shabbaton was truly ‘ five

star’ and was ‘out of this world’!

FWD transferred me to another world, another realm, from lone-liness to a place of unity. From the moment I was welcomed, I instantly felt at ease…The motto: Every girl shines through as an individual, along with the attitude that each girl’s presence counts, clearly indicated the goal of this Shabbos: to bring us all closer to-gether… May Hashem repay you for everything…Let

ters

Spring 5767 | 1� | Going ForWarD

This poem was included in the souvenir baskets handed out at the Shabbaton.

StaR StRuck SHabboS

The night seems full of darkness,Yet the stars illuminate,Sharing of their brightness,In so many different ways.With light and warmth, their raysForm a galaxy,Each star in its place,Patterned so specifically.A collection of girls from all over,Each one a shining star,Aren’t you delighted,That a part of them you are?So here is a package for you,It includes anything you may need,Luxe like a five STAR hotel,To give you a good night sleep.The pillow is essential,Toiletries – can’t do without.The ‘chachkes’ are the luxuries,Of stars it’s all about.ohcfufk rpxn vbun,Hashem knows the amounts,Every star makes a difference,Every girl counts.We say good night to you,Enjoy the souvenirs,And hope memories of this Shabbos,Will stay with you for years!

Rising to the Challenge

about twenty people with both diabetes and celiac gathered to share coping techniques and prac-tical information with each other. Lynn senecal, Cde a renowned diabetes educator from Califor-nia, addressed various issues of this dual condition, which often makes life very complicated. her useful advice, accompanied by a slide presentation, proved to be extremely enlightening to the au-dience.

a young woman with celiac then shared some practical tips on deal-ing with this condition, from a hei-mishe balabuste’s perspective. her tried-and-proven recipes opened a new door for many of the atten-dants, as one parent exclaimed, “all i was giving my child was rice cake and rice cake and rice cake! i didn’t know we can buy and bake all those delicious choices.”

Teves 5767 – Jan. ‘07

Friends With Diabetes Hosts

Successful Annual Parents Seminar

between cooking and carpooling, learning and earning, shopping and disciplining, parents have so


many obligations and responsi-bilities. Get a group of them under one roof and you’ll learn countless different ways of dealing with life’s ups and downs.

Mothers and fathers of children with diabetes have one more thing to learn about and keep up to date on. With diabetes being what it is, daily responsibilities take on a new rhyme: testing and counting, learning and monitoring…

Friends With diabetes recognizes the challenges parents of chil-dren with dia-betes face, and is committed to providing them with support, education and i n f o r m a t i o n that will help the entire family adjust more eas-ily to these issues.

seventy two families gathered for an inspiring and enlightening evening at the Metropolitan Jew-ish Geriatric Center, with special thanks due to the center’s admin-istration. dozens of mothers and fathers were able to network with many other parents facing the same issues.

Upon entering the hall, each par-ticipant received a personalized folder, complete with free samples

of previous diabetes magazine edi-tions and special “business cards” to share with other attendants.

rabbi Meisels warmly greeted the participants, pointing out that the number of families present corre-sponds to the shem hachesed (one of hashem’s names). he continued by citing the blessing Yaakov gave Yosef in the weekly parsha. “inter-estingly,” rabbi Meisels explained, “the blessing focuses on Yosef’s children, and is not a blessing for Yosef himself. Obviously, the

greatest blessing a person could receive is when his children are blessed. Certainly, the parents who gathered tonight on behalf of their children indicate that for them, too,

the greatest blessing is additional help for their children.”

the event’s distinguished guest speaker was Jeff hitchcock, Presi-dent of Children with diabetes – an organization that serves thousands of families. drawing on his vast experience in dealing with people with diabetes, Mr. hitchcock discussed numerous products from the consumer’s per-spective, giving much appreciated practical advice and insight. some of the products he discussed were

In a sense, it was like becoming

mechutanim - an occasion calling

for much celebration!


Dear

Rabbi Meisels,

I really enjoyed the meeting, it was great,

and I think we all got so much from this

presentation.

It brought all of the parents together,

especially the women, who were able to

connect and vent their frustrations.

Even though we’re different, it all

boiled down to the same thing – how

we deal with diabetes and the love

we all have for our children.

I’m sure you must realize that all

of your hard work pays off.

S. N.

Dear Rabbi Meisels,

I wanted to thank you on behalf of my husband and myself for the very informative seminar we recently attended

in New York in January. Not only did we get some useful up-to-

date info on new products, we also got some great tips on how

we can manage our son's diabetes better. Often enough, doctors

don't have the time, or experience with enough products that are

available, so they cannot give the much needed hints and tips that

are out there. This particular gathering was especially momentous

for me because my husband and I never get the opportunity to be in

a room full of Jewish parents, let alone frum ones. We attend support

groups and lectures here in Chicago, but never in this type of setting.

At the meeting, I turned to my left, there was a frum parent of a child

with diabetes. I turn to the right and I see another frum mother. I hope

nobody noticed my eyes getting misty. Rabbi Meisels, what you and

your wife offer to us, parents and son, and to the many other families,

is incomparable to what we receive out here in Chicago. I received such

chizuk from looking around the room and seeing every type of Jew parent

out there advocating for their children. This forum happened because of

your dedication and commitment to helping us. Hashem should give you the

strength to continue to educate, inspire, and help all of us. With much Hakoras Hatov, Mrs. F.P.S. Exchanging the business cards with other parents was a brilliant idea. We

actually made contact with a boy our son's age and we went to visit him during

our stay in New York. This was the first time we met a frum boy or girl his age

with diabetes .Finally, our son had someone with whom to compare "pump notes".

No words can describe our hakoras hatov for all you have done for us. Just knowing that there is someone who understands and cares is the biggest chizuk. Yasher koach!Z. C.

Letter

s


displayed on a slide screen so that the listeners should be able to fol-low the discussion completely. he also spoke about products that are being developed and will probably become available in the future. after his informative speech, the attendants had the opportunity to ask questions and benefit from Mr. hitchcock’s advice.

rabbi Yechiel Kaufman of boro Park Jewish Community Center addressed the gathering with his inspiring words. rabbi Kaufman focused on dealing with new chal-lenges, describing some of his experiences with boys that have diabetes.

at the event, several prominent companies exhibited their prod-

ucts. Pump Wear had a beautiful display of specially designed cloth-ing for people who wear pumps. bd handed out useful gifts, and dexcom presented their continu-ous glucose monitor, which many parents were thrilled to finally see firsthand.

an important part of the evening was the sharing and Caring pro-gram, through which parents were able to pair up with other families which have children the same age as theirs, by sharing their personal-ized business cards with each oth-er. in a sense, it was like becoming mechutanim - an occasion calling for much celebration!

With much chizuk and newfound friendships, the participants dis-


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persed. the letters, phone calls and emails that poured in after the event were full of appreciation, most of them calling for more such events in the future.

Friends With diabetes thanks ev-eryone who attended, and hopes to continue providing more such inspiring environments in which to network with each other.

Shevat 5767 – Feb. ‘07

Friends over the Ocean

On a recent trip to eretz Yisroel, rabbi Meisels of Friends With dia-

betes arranged to meet a group of FWd members who are in phone contact with the organization.

the gathering took place in the home of Mrs. Lefkowitz, who ar-ranges diabetes support groups and shabbatons in israel.

“it was wonderful to finally meet all these people in person,” rabbi Meisels commented. “i only regret i had so little time to spare of my �0-hour stay, which included a wedding.”

For true Friends, even the oceans aren’t wide enough to keep them apart!


T he lights are dimmed, the music reaches a crescen-

do and the curtains part… At the microphone, excited fans enthuse about the stars of today’s show.

“Since I started taking Byetta, I’ve lost nine pounds! I finally feel like I‘m really doing something to combat my [type 2] diabetes!”

“This past Yom Kippur was the first time I was able to avoid the stubborn high blood sugars that I commonly encounter after break-ing my fast. The credit goes mainly to Symlin, which I started taking a short time before.”

“A medication for type 1s? It is un-believable… I have always been so

helplessly frustrated by the peaks and valleys of my blood sugars, but now that I’m on Symlin they’ve flattened out considerably…”

If you are a bit skeptical hearing what people have been saying about Byetta and Symlin, then we don’t blame you. The diabetes medication industry is one that has often promised more than it delivered, with many a drug in the limelight performing poorly in patients. But Byetta and Symlin, in many ways differ from the drugs we’ve been seeing until now, so open the curtain on a landscape of new possibilities for patients with diabetes.

Setting the stage for a new era in diabetes management

PASS- iF The TeChniCAl deTAilS ARe noT FoR you!


You’ll notice a lot of parallels be-tween these two rising stars, and not just because they’re manufac-tured by the same company. both replace hormones that are missing or deficient in people with diabe-tes. they act similarly in the body, addressing the postprandial (after meal) blood sugar rise, which is so prevalent and problematic in people with diabetes. both medi-cations slow food digestion and can aid weight loss. and even their side effects are similar, with both byetta and symlin potentially causing nausea in new users. they cannot be taken orally, but must be administered by injection.

in fact, it may be claimed that the two can probably be used by people with type 1 and type 2 dia-betes interchangeably. although marketed primarily to the type 1 as an adjunct to mealtime insulin, symlin is indicated by its manufac-turer for insulin-using patients with type 2 diabetes as well. and vice versa for byetta, which is targeted specifically for type 2 diabetes, but has already been prescribed off-la-bel by certain physicians for some of their type 1 patients (although it has not been studied in patients with type 1 diabetes and it is not a substitute for insulin).

Behind the Scenes: How Byetta and Symlin work

there’s a disheartening puzzle in diabetes. despite the many studies showing that a lower hemoglobin a1C leads to less risk of complica-tions, some people with good a1Cs continue to develop complica-tions. the key to this discrepancy may very well lie with postprandial (after meal) blood sugars. a quick swing in blood glucose following a meal might not be reflected in a1C value, but it may still be very destructive to a person’s health. in fact, it has been demonstrated recently that variability in blood sugars are what trigger the most damage to the body.

What causes these debilitating highs? here‘s the short answer: people with diabetes lack key hormones, specifically amilyn and GLP-1, which normally lower blood sugars after meals. as for the long answer, let’s describe two impor-tant functions these hormones perform in the body to stabilize blood sugars after food is eaten.


because the body has a constant need for glucose in order to func-tion, the pancreas produces glu-cagon (which signals the liver to produce glucose) throughout the day. amilyn and GLP-1 are two hormones that cause levels of glu-cagon to plummet after eating, when an influx of sugar arrives in the body, but both are missing or ineffective in people with diabe-tes. (those with type 1 diabetes do not produce amylin at all and people with type 2 diabetes are resistant to the hormone, while GLP-1 is low in all cases.) because of this deficiency, glucagon may actually rise after eating in the set-ting of diabetes. an additional ef-fect of amylin and GLP-1 is to pace the rate of gastric emptying and the absorption of glucose into the blood stream so that blood sugars do not rise at once. because they are often missing this regulation, stomach emptying in people with diabetes is about �0% faster than in the average individual. When sugars are absorbed so rapidly, it is understandable that the body has a hard time coping and keeping blood sugar levels controlled. so the lack of amylin and GLP-1 trans-lates into postprandial high blood sugars in people with diabetes.

While administering more insulin does not solve the problem of postprandial highs, symlin and byetta can work wonders because they replace amylin and GLP-1 (respectively), thus responding directly to the cause of these high blood sugars.

Spotlight on Symlinamylin has been known to re-searchers since the 1970’s, but its recent evolvement as injectable symlin (pramlintide) represents a new frontier in treating type 1 diabetes. Users report a virtual elimination of blood sugar swings after meals as well as a reduced appetite. in a study, people who took symlin ate 2�% less food.

symlin has not yet been heav-ily prescribed and so there is still much left to learn about it. the following collection of informa-tion and tips will be helpful, but remember that as always, every in-dividual is unique and will respond differently.

AdMiT- vAluAble inFoRMATion FoR

SeRiouS SyMlin FAnS


Hormone Mathematics: Balancing Symlin and

Insulin for Superior Control

symlin has to be injected before every meal, starting at a company-recommended minimum dose of 2.� units (1� mcg) for type 1s, and 10 units (60 mcg) for type 2s (who seem to be resistant to symlin like they are to insulin). the dose is cur-rently fixed, but who knows? the wave of the future may hold sym-lin-to-carb ratios, or even symlin-to-insulin ratios, which may differ according to sensitivity at various meals of the day. an experiment was even performed using symlin in an insulin pump, the hypothesis being that the body needs basal amounts of symlin throughout the day in addition to larger doses with meals.

because symlin is so effective at curbing blood sugars, insulin doses may need to be lowered by as much as �0%. if your basal rates are accurate, you will probably di-minish them only slightly.

the timing and distribution of the insulin will need to be adjusted be-cause once symlin’s effect wears off, users can experience a delayed glucose rise. as one user describes graphically, “[in] my imagination, [once] symlin walks off stage… the curtain opens and there are raging carbs all hot and firing.”

so how can you avoid this unpleas-ant show?

Patients who wear pumps can make good use of the extended bolus. doctors usually start with a 1-hour extended bolus which may need to be shortened for high-carb meals and lengthened for foods that are higher in fat and protein. Others experiment with dividing the insulin dose, taking part of it immediately before eating and the other part as an extended bolus spread over one or two hours.

Others bolus as usual before eating, and then take the same amount again one hour later.

For those on multiple injections, rapid-acting insulin should be administered just before or even after the meal, depending on the pre-meal glucose level. in fact, many providers with experience using symlin find injecting after meals a better option, as the in-sulin dose can then be matched to the amount of carbohydrates


actually consumed. if insulin is ad-ministered after eating, correction doses for pre-meal hyperglycemia should still be taken before the meal. (this may be understandably difficult, as it would mean taking an extra injection. Pumpers would have a much easier time here!)

the drawback to this method is that people with diabetes have been somewhat “programmed” to administer boluses before meals (or even to wait a little while between injecting and eat-ing) and may completely forget to inject after eating. For this reason, it may be helpful to use the older regular human insulin (remember that?) which could be injected be-fore eating, but would only begin working about �0 minutes later. because correction doses should still be administered with a rapid-acting analog, the two could be combined in a cocktail.

the current recommendation is not to mix insulin and symlin in one syringe, but we may yet see this warning rescinded (as has of-ten occurred in the past).

the increased risk of insulin-in-duced hypoglycemia when using symlin can be dramatically re-duced by lowering the mealtime insulin dose upon symlin initia-tion, starting symlin at a low dose and slowly titrating to the maxi-

mal dose, frequent monitoring of blood glucose and the proper setting of basal doses. (a continu-ous glucose monitor would be very helpful, granting the wearer a comprehensive view of symlin’s influence on blood glucose.)

if your blood sugars are low or declining before a meal, you may be well advised to skip the symlin altogether. On the other hand, if your blood sugars are falling after the meal, treat but don’t overtreat the low; the symlin will wear off on its own in a short while.

Byetta in the limelightMany current type 2 medications have two serious drawbacks: they can actually encourage weight gain, which is a major root of type 2 to begin with, and they can potentially cause hypoglycemia. byetta’s impressive appeal prob-ably begins with its reputation as a weight loss aid (because it makes users feel full), and it cannot cause hypoglycemia because its action is

PASS- iF The TeChniCAl deTAilS ARe noT FoR you!


glucose dependent, meaning that it lowers glucose in the body only when sugars are too high. (Last issue‘s article on Januvia presents a more thorough explanation of this concept.)

derived from the saliva of the Gila monster, byetta (exenatide) was approved by the Fda in april, 200�. in its first year on the market, more than 1 million prescriptions were written by �0,000 doctors. in-jected twice a day with a prefilled pen, there are preliminary reports about once daily, once weekly, and even once monthly applications. Others are working on a similar drug that would be taken orally.

How does this wonder-drug work?

incretins, including GLP-1, are nor-mally secreted by the endocrine cells of the intestine after meals to enhance insulin release while sup-pressing glucagon release from the pancreas.

as explained earlier in this article, glucagon is usually released from

the pancreas only when blood sugar levels are low, and glucagon secretion is shut off after meals by insulin and GLP-1. in those of us with diabetes, however, GLP-1 and insulin levels are low, which re-sults in high glucagon levels. this combination of hormonal signals mistakenly tells the body that it is starving when it really is not. thus, the liver continues to pump out glucose, even after a meal, and this is thought to be a major cause of postprandial hyperglycemia in diabetes. byetta seeks to fill in for the body’s lack of GLP-1, thereby helping to smooth out blood sug-ars after food is ingested.

People with diabetes will often struggle maintain fasting-morning blood sugar numbers in range, this is also due to the miscommunica-tion of the liver which is producing too much glucose. byetta address-es this as well, by decreasing the glucose output of the liver.

byetta can also be seen as a kind of lifeline to an overworked pancreas. in type 2 diabetes, insulin-produc-ing beta cells in the pancreas may become impaired because they can no longer compensate for the insulin resistance that comes, typically, with excess body weight or aging. byetta has been shown to impair beta cells in animals, enabling the secretion of more in-


sulin to control blood sugars. For this reason, experimentation with the drug on those with newly di-agnosed type 1 diabetes or those who underwent beta cell trans-plants is currently underway.

Some Sidelights on Byetta and Symlin

Storage Symlin is reported extremely sta-ble in heat, as long as it is chilled before use. You can call the manu-facturer at their toll free number with any questions regarding symlin’s shelf life and viability after it is exposed to heat.

byetta: as we go to print, new and exciting storage guidelines were released by the manufacturer. byetta pens can now be kept at a room temperature anywhere from �6 degrees F (2 degrees C) to

77 degrees F (2� degrees C) after first use. refrigeration is no longer required after first use.

Side-effectboth symlin and byetta can cause nausea in new users, but the good news is that this uncomfortable side-effect will probably diminish over time.

try eating smaller meals more frequently and eating within an hour after injecting the drug. in fact, the sooner you eat something after taking byetta or symlin, the less the chance of nausea. One user relates, “ i find that i only have a window of about 1�-�0 minutes after administering symlin [during which] i can eat; after that my ap-petite is gone.”

try lessening the dose. some people have been able to maintain the benefits of symlin on as little as 1 unit, which is a dose almost anybody can tolerate.

Pay attention to the foods you eat to find out which ones work best for you; many have discov-ered that it is worth their while to avoid spicy and fatty foods. Ginger in its many forms (including ginger snaps, ginger gum, ginger ale and


ginger pills) is recommended often.

Experiment with these meth-ods for fighting nausea, which range from the exotic to the tried-and-true: People have reportedly been relieved by everything from a cup of hot water sipped slowly to sugar-free mints, chamomile tea, saltines, rice crackers, antacids, hypnosis and deep breaths. One person found that taking a long walk helps. (it’s a good idea in any case.) as a last resort, you can always take either a prescription or an Otc drug to curb the nausea.

Remember, your mileage may vary! One user shares, “[i don’t usually expe-rience nausea anymore, but] i still get the nausea if i exercise right after taking symlin”.

On Shabbosbyetta and Symlin may be taken on Shabbos, according to our rav.

in Conclusion…

Do let us know about your own experience using Byetta or Symlin. We are pretty confident that you’ll join us in an enthusiastic round of applause! And meanwhile, we all await the show’s grand finale: The Cure.


The artist dips his brush into the patch of lilac paint, then watches as dainty flowers sprout on the canvas. a sunny garden scene is unfolding before his eyes. a cottage dipped in red tulips, a barn surrounded by tall, wavy grass stalks, and a small pond with a f lapping duck blend togeth-er beautifully in his nearly finished painting. he dabs his brush in pale yellow, bright pink, deep blue, lime, rose, and white. Fluffy clouds appear in the sunny sky, and a lone squirrel appears on a high branch in the graceful maple tree.

to the inexperienced eye, the painting contains only bright,

sunny colors. Yet, if we would care-fully observe the artist, we would be surprised to see him dip his paintbrush in the patch of black paint quite often.

“Why does he use black paint on such a sun-drenched summer scene?” we won-der. “he’s ruining the painting!”

if we would only contain our criti-cism until the artist completes the painting, we’d see how the black shadows behind the cottage and barn make the scene appear so much more real. the black shadow behind the tall maple tree makes us feel the welcome relief of the shade. not only do the black

“Why does he use black paint on such a sun-drenched

summer scene?”


patches on the canvas not ruin the painting, but they enhance it beyond measure.

so too, explains the saintly rebbe of rimonov zt”l (in his sefer be’eros hamayim), is with the black patch-es that appear in our lives.

the Master artist created a perfect world, full of beauty, tranquility, and joy. at ev-ery moment of the world’s exis-tence, hashem is doing constant chesed with his creatures. he pro-vides the needs of every part of creation, from the vegetation to the insects, and from the animals to his dear children.

Where do personal hardships and troubles come into this sun-drenched picture of chesed? Why does the artist mess up the beauti-ful painting with black patches?

Our faith in hashem is everlasting, and we believe that every struggle is for our ultimate good. the dif-ficulties we experience are part of the bigger picture, the greater scheme of events. We are but a speck on the canvas, unable to see how the black patches form graceful shadows on the lush grass. the trick is to trust the artist completely.

When we experience life’s hard-ships, dealing with the actual situ-ation often draws every ounce of our perseverance and courage. being resentful only puts an ad-ditional burden on our shoulders. but if we can accept the seeming blights in the picture with com-plete emunah, we will be able to grow from these challenges. We

will use these ni-syonos as spring-boards for growth, for connecting with hashem.

all evidence points to the fact that the artist is about to complete the picture. the final strokes are being made, the final

details etched onto the canvas. it is at this stage of the drawing when most of the black patches are ap-plied.

Let us preserve, let us be strong! Let us retain our simcha and hap-piness, despite the hardships we experience. We are far too small to understand what part of the painting we form, but let us place our trust in the artist. he put each of us in the best place possible to enhance his masterpiece.

the full splendor of the paint-ing will be revealed soon, very soon. May we all merit rejoicing together at the final redemption, int ubhnhc vrvnc.

Where do personal hardships and troubles come into this sun-drenched picture of chesed? Why does the Artist mess up the beautiful painting with

black patches?

If a member of your family has type 1 diabetes you

may be eligible to participate in a research study testing

whether oral insulin can prevent or delay diabetes.

For more information call:(212) 851-5425Or visit:www.diabetesTrialNet.org

Type 1 Diabetes TrialNet is a network of 18 international diabetes research centers supported by:

What ifthe future of

type 1 diabeteswere in your

hands?

4303-DIA Oral Insulin Text Ad-v3 2/26/07 4:06 PM Page 1

Congratulations to Dr. Svetlana Ten, Di-rector of Pediatric Endocrine Division In-fants and Children’s Hospital of Brooklyn at Maimonides, on the birth of her first grandchild.

Going ForWarD | �0 |spring 5767

Recent Mazel Tovs

Mazel tov to member and their wives upon the birth and bris of their baby boy

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Mazel Tov Dr. Moshe Weiss and his wife, pediatric en-docrinologist in Rockland County, on the birth and bris of their baby boy.

Spring 5767 | �1 | Going ForWarD

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