I don’t know where it came from or how it happened, but I developed a nasty infection from my latest infusion site. Check this out:

At first I just thought it was another skin irritation due to my stupid allergic reaction to medical adhesives.  But this one was swollen and sore, and even hurt when I walked.

Having some experience with bacterial infections that can turn venomous, my hubby insisted that I go see a doctor right away. That of course meant dropping everything for a 20-minute trek out to my primary care physician, whom I barely ever see.  Naturally, she wasn’t in on Tuesday, so ended up in the suite next door with some on-call doctor who clearly didn’t know a thing about Type 1 diabetes.

The sight of my OmniPod on my shoulder made him jump.  Then he saw me checking my sugar, and asked “what my number was.” When I replied, “well, it’s 113 right now,” he broke a smile and said, “Oh, so you’re in very good control!”  As if one number at any given point in time determines your diabetes control. Sheesh! You’d think a doctor would know better than that.  After that I kept thinking, “113 is actually a little risky this soon after breakfast.  What if I’d reported a number in the 200’s?  Would you be admonishing me now for my poor control?!”

Anyway, he was nice otherwise.  After hearing my story, he opted for an antibiotic that was “less likely to cause allergic reactions” (thank you very much). I have to take the pill four times a day for 10 days, and I am instructed to use warm compresses on the infection site just as often, to increase blood flow. OK, I’m pretty used to medical inconveniences at this point, but what about people who have real jobs in offices? What do they do if their bellies need warming four times a day?

In the end, the only thing that matters is whether this has any long-term impact on my ability to keep pumping.  God knows I don’t want to return to injections!  Again, it’s not the pokes themselves that bother me, but the complexity of struggling to control my BG levels with two different insulins and varying insulin:carb ratios throught the day. Not to mention how much more difficult corrections are to figure out yourself.  Ugh!

But I can see I’m not the only pumper who’s ever experienced an infusion site infection, or other complications with getting your site right.  Stupid, sensitive skin.

If there is such a thing as a legendary diabetes educator, then Gary Scheiner is it.  I’ve had the pleasure of meeting with him at various diabetes events, and let me tell you, just sitting down to breakfast with this guy is an education.

A Guest Post by Gary Scheiner, MS, CDE

Having recently returned from the Diabetes Exercise & Sports Association International conference in Toronto, Canada, I find myself inspired by the athletic accomplishments of so many people with Type-1 diabetes.  What’s even more inspiring than their ability to compete in (or simply complete) so many challenging events is their ability to manage blood glucose levels under some of the most demanding conditions.  We’re talking about mountain climbers, Olympic swimmers, Ironman Triathletes, cross-country cyclists and champion bodybuilders, just to name a few.  Definitely inspirational stuff.

What leaves me less than inspired is the continued lack of attention given to physical activity in determination of insulin doses.  We all know that physical activity impacts insulin’s effectiveness and blood glucose levels.  But think about it:

Which blood glucose meter has an easy method for entering physical activity into the meter’s memory?  Which pump incorporates an exercise adjustment into the dosing process?  How many logbooks have designated space for recording physical activity?  How many downloading programs include physical activity in the reports/displays?

Since its inception, the American Diabetes Association has proclaimed Insulin/Medication, Food/Carbs, Exercise/Physical Activity and Blood Glucose Monitoring to be the cornerstones of diabetes management.  Plenty of attention is given to adjusting insulin based on carb intake and blood glucose levels, so where’s the beef when it comes to adjustment for physical activity?

Like many of you, my exercise varies from day to day.  I experience major blood sugar drops during certain forms of exercise, mild rises from others, and delayed drops following prolonged/intense activities.  Even at work, physical activity plays a role.  When I spend lots of time sitting at a desk, my blood sugars tend to run higher.  When I’m up and moving around a great deal, they tend to run lower.

Because physical activity affects both hormone levels and the body’s sensitivity to insulin, adjustments need to be made.

When activity increases, mealtime bolus insulin usually needs to be reduced.  When activity decreases, boluses need to be increased.  It’s a lot to think about!  And that doesn’t even touch on necessary adjustments to basal insulin during and after heavy exercise.

The trouble is, short of thinking about it constantly, we just don’t have very good tools for making these adjustments.

Wouldn’t it be nice if the logbooks included with each meter had space to record physical activity?  It would be much easier for us (and our healthcare teams) to determine appropriate dosage adjustments.  Same with the blood glucose meters, continuous glucose monitors, and downloading/analysis software.

And wouldn’t it be just wonderful if pumps incorporated an activity multiplier into the bolus calculations?  How simple it would be to add 20% to a bolus if an “evening in front of the computer” is planned, as opposed to a 33% reduction for an after-dinner bike ride.

At this point, we have two jobs to do:

1. Talk to the representatives of the device companies (pumps, meters, CGMs, software) about taking physical activity seriously when designing their products and accessories.

2. Until that happens, THINK ACTIVITY every time you make an insulin dosing decision.  Sure, it’s one extra step.  But it’s easier than counting carbs, and you learned to do that, didn’t you?  I sure hope so!  (If not, I know a great book you can order:  The Ultimate Guide to Accurate Carb Counting.  Author’s a genius, and an all-around good egg.  A bit preachy, but a good egg.)

****

Nice to know that Gary also offers his special brand of diabetes education consulting remotely, via phone and Internet, from his practice Ingegrated Diabetes Services outside Philadelphia, PA.

I noticed that Dr. Alan Rubin’s recent Guest Post here at The Mine stirred up some heated discussion over conflict of interest (COI) — an issue that seems to lurk behind every corner in the business of health and medicine.

When is it OK to be sponsored by pharma company? And when is it OK to trash them, even as they produce the medicines and devices that keep us alive?

I’m no authority on this complex issue, but the way I see it, there’s a tricky dichotomy going on here: We patients (and doctors and CDEs, too?) have a love/hate relationship with the pharma industry.  On the one hand, we depend on them and deeply appreciate their work. On the other hand, we sometimes view them as big, greedy conglomerates out to exploit us all.  Unfortunately, a number of recent scandals back the latter view.

Nevertheless, I think we, the Diabetes Community, just have to accept that we are symbiotic with pharma.  We need them as much as they need us, and vice versa.

So where do we draw the line when it comes to sponsorships, promotions, and such?

Personally, I think it’s OK to promote a book (like Dr. Rubin’s) that has something valuable to say — even if that something is about the overhype of other goods and services.  With the flood of information and entertainment vying for everybody’s attention these days, how would we know about any good books without proper promotion?

The way I see it, there are basically three pretty obvious cardinal sins of COI:

1) Non-disclosure — it’s not OK to hide connections or agreements an individual or company may have with another.  This is the big imperative we now call “transparency.”

2) Hypocrisy — also definitely not OK to falsely present yourself as righteous on certain topics, while playing the other side of the field as well.  So if you’re going to be someone who shouts from the rooftops about the evils of Big Pharma, for example, then you should not be accepting sponsorships from same.

3) Exploitation — no inappropriate hype of something (or some group) where it doesn’t belong. No misleading people (patients) into buying things they don’t need or paying exorbitant prices for no good reason.

I haven’t told you anything new here.  These rules apply to any industry, and in fact to credibility in general.  It’s just that since diabetes is both a deadly disease and a billion-dollar industry, it’s inevitable that interests conflict.  So it’s important for us all to keep a (constructively) critical eye peeled, I believe.

Your thoughts?

Now this is interesting.  Yesterday I received an update from the folks at Manhattan Research on the “Top Pharma Product Site 2008 list” from their latest ePharma Physician® study. To be clear, this study looks at the top product sites visited by doctors, not patients or consumers:

Top 10 Product Sites Visited by Physicians in 2008

Ranked by Number of U.S. Primary Care Physician Visitors

1. Januvia

2. Actos

3. Chantix

4. Gardasil

5. Actonel

6. Vytorin

7. Amitiza

8. Byetta

9. Avandia

10. Aciphex

In fact, the study polled primary care physicians, not endocrinologists in particular.  Note the top treatment brand sites are from Januvia, Actos, Byetta, and Avandia.

And the highlighted quote included was as follows:

“This year’s rankings show that market events, rather than just advertising alone, can be critical drivers to brand websites,” points out Meredith Abreu Ressi, VP of Research at Manhattan Research. “Pharmaceutical companies need to ensure that brand websites contain the latest, most accurate content possible and can be found relatively easily by physicians using search engines to research pharmaceutical information.”

By “market events” I’m assuming they mean scandals and safety scares.

What’s fascinating to me is the lack of any sites having anything whatsoever to do with insulin.  Also, metformin did not make the list, although it is the most prescribed diabetes drug in the United States. I guess if it’s safe, it’s not that interesting (?)

As a patient with Type 1 (insulin-dependent) diabetes, I personally spend a lot of time looking at the web sites from Insulet (makers of my OmniPod pump) and those from Medtronic, Abbott Diabetes, Roche, Animas, DexCom (CGM systems) and the like.

I know most patients with Type 2 diabetes take oral drugs. I wonder what their Top 10 List would look like? And yours?

“Mom, what’s the weirdest thing that ever happened to you?” (my 9-year-old on Saturday)

“Umm, getting diagnosed with diabetes, I guess… Yes, definitely the diabetes.”

“But you knew about them before, right?”

“Knew about who, honey?”

“The diabetes! And what they do and stuff…”

School started today. I sure hope they don’t change her too much.

I may be the last would-be weight watcher in the country to discover the South Beach Diet. The cover of the book by Dr. Arthur Agatston, MD, brags that it’s a New York Times bestseller, and it even sports a pop-out button stating “lose belly fat first.”  Definitely not my usual thing.

But my hubby read the book last year and hasn’t stopped talking about it since. “It’s the only diet that’s sensible, that teaches you how to eat right in the long-term…” he says. “In fact it’s not a ‘diet’ at all, but a way of life.” From the beginning, he insisted that with my carbohydrate-shy and gluten-free eating habits I was essentially on the South Beach Diet by default. Hmmm.

I took advantage of the transatlantic flights all on my own this summer (!) to read the book at long last.  Wisdom indeed. No wonder my partner understood the the basics of Type 1 diabetes eating principles much better after reading the first 90 pages or so of this book. Dr. Agatston explains the fundamentals of blood glucose spikes, and why all those excess carbs in baked goods are worse than unnecessary. He almost made me warm up to the low-carb fervor. Almost.

But — and this is the linchpin — he’s the ultimate pragmatist, recognizing full well that diets that are too complex or too restrictive “are just too burdensome to sustain for long.” Amen.  So while I’m warming up to mini vegetable quiche cups and “desserts” made out of ricotta cheese, I’m also looking forward to Phase 2, when you get to add some “good carbs” back in to your repertoire.

Oh, and one other thing: the version I’m testing out is something a colleague once called “The North Beach Diet” (no, not the official parody, just a reference to the Italian/Beatnik section of San Francisco).  It’s the same as the South Beach Diet, but with coffee and wine allowed. I mean, come on, our diabetic lives are restrictive enough!

We never really get a vacation from diabetes. Never.  But this last month is about the closest I’ve come since diagnosis.  What a treat!

Despite a few D-blips here and there, my BG management went smoothly enough to recede to the background while I enjoyed sun, surf, friends, family, museums, walks in the woods, and a few too many calories, I daresay.  In a sense, being in Europe with so many faces from the past transported me to an earlier time — a simpler time, before the children, and in particular, before my life was all about this cumbersome disease.  It felt like a visit to my former life, and I liked it.

It also didn’t hurt that I was pretty much offline for nearly three weeks (aside from a peek in now and then).  So I also feel like I’ve been on a getaway to a place called Planet Offline, a relaxing spot where your day is not punctuated by urgent emails and Google Alerts; where your head isn’t anchored in front of a screen; where, in fact, your cell phone rarely rings.  I’m sure I couldn’t stay in that place too long without going batty, but for a short stopover, it was almost as refreshing as the spa.

A huge enormous Thank You to all my wonderful Guest Bloggers for making this break possible!  The Guest Post series went so well, in fact, that it’s going to remain a regular feature here at The Mine.  (Please let me know which editions you liked best, and what you all might like to read more of.)

And now for some notes from my travel log:

* Maintained my perfect record in “don’t ask/don’t tell” diabetes air travel; never once been questioned about all those sharps in my bag.

* Changed my insulin pod in a gritty beach bathroom, in the crumbling backroom of a historic café, and in two different airplane lavatories.  Note to self: pick a lavatory with the baby changing table, for goodness’ sake. You need the wiggle room!

* Discovered that Bloody Mary’s are diabetes-friendly!  The extra-zesty Mexican version didn’t raise my BG, even when I was a tad hungover from a long night at Cabo Wabo (not my idea, I swear )

* Serious lack of low-carb/no-carb beverage options in Europe. If I see another bottle of Coke Light anytime soon I’m going to puke.  Crystal Light: where are you when we need you?!

* Gained at least 3 pounds enjoying gluten-free treats. (It feels like more.) Getting serious about weight loss/maintenance strategies now. More on that later.

Anyway, I’m baaaaack.  A bit jet lagged and snowed under.  A bit befuddled at the pace of my US existence.  But very appreciative of this American life we’ve built just the same.

I met Hope Warshaw a couple of years ago at the annual ADA conference, when I interviewed her on eating with diabetes.  She’s smart, down-to-earth, and witty.  Just the kind of expert you wish you could take home with you!

A Guest Post by Hope Warshaw, registered dietitian, CDE, and famous food author

As you put carbohydrate counting into everyday practice do you go from one wild ass guess to the next? That’s understandable! At best carb counts are educated guestimates (my non-Webster approved word) for myriad reasons: the methods used to analyze/provide carb counts on nutrition labels, mysterious math allowed by FDA on nutrition labels, limited point-of-purchase nutrition facts for produce, and hidden carbs in restaurant foods; to name a few.

Accurate carb counting is not, as some diabetes care providers suggest, a set of simple skills. It’s a constant challenge within the context of juggling real life and diabetes. Check out these practical pointers to increase your number of educated guesses.

Build Your Top 100: Use the premise that we’re creatures of habit when it comes to foods to your advantage. Think about it. Do you assemble meals and snacks from the same 100 foods day after day? Rather than constantly searching for the carb counts of the same foods and adding up your counts, spend a couple of hours once building your top 100 list, then revise on occasion. Here are the steps:

1.    Brainstorm and record a list of the foods you regularly eat. Look in your refrigerator, pantry, and freezer.

2.    Record the amounts of these foods you eat. (Do this over a few weeks – as you eat them. Weigh and measure the foods to maximum accurate carb counts.)

3.    Determine the carb counts from resources (below).

4.    Total the carb counts for common meals and snacks.

5.    Make this information portable and carry it with you.

Create your history: Continuing with the creatures of habit premise, record a few notes about your blood glucose responses to these meals. Think about how you could improve post-meal BGs – less/more food, more insulin, take insulin earlier, or extend part of the dose.

Train eyes and hands by weighing and measuring foods (on occasion): Weighing and measuring foods constantly is a pain and most people don’t do it. That’s understandable. But consider doing it on occasion to familiarize yourself with and keep you honest about portions and carb counts. Well trained eyes and hands assist you at home and when you eat out. As a mental reminder and for quick access, keep measuring equipment on the counter.

Purchase a high-tech food scale: A food scale ($40 – $100) that provides the gram weight of foods and/or the carb counts of a database of foods can be helpful. A source is The Diabetes Mall.

Learn carb counts of restaurant foods: Again put the creature of habit premise into action. You likely eat similar foods from a short cadre of cafeterias, fast food joints and restaurants and order from a similar handful of menu options. Focus your time and efforts to gather the carb counts for these foods through:

-    National chain restaurants: Walk up and order restaurants often provide complete nutrition information on their websites whereas the sit-down and order chains do not. Little to no information is available for independents.

-    Worksite cafeteria, local breakfast or sandwich shops: Ask to see the nutrition facts labels (if available) for foods you regularly eat. Example: bread, bagels, muffins, coleslaw, three-bean salad, etc.

-    Carb counts of ethnic foods: Check out the nutrition facts of similar foods in the supermarket – refried beans, salsas, tortillas, Chinese sauces, or frozen stir fry dinners. Peruse cookbooks. Pay particular attention to the hidden carbs—sugar in marinades, corn starch as thickeners.

Resources for Carb Counts:

Online:
-    www.ars.usda.gov/nutrientdata (USDA’s National Nutrient Database)
-    www.calorieking.com
-    www.dietfacts.com
-    www.nutritiondata.com

Offline (books/pamphlets):
-    The Diabetes Carbohydrate and Fat Gram Guide, by LeaAnn Holzmeister, RD, CDE. American Diabetes Association

-    The Doctor’s Pocket Calorie, Fat and Carbohydrates Counter, by Allan Borushek. Family Health Publisher. (Updated annually and available here)

-    Guide to Healthy Restaurant Eating, 3rd ed. American Diabetes Association. (Nutrition information for the top 60 U.S. chain restaurants)

-    Eat Out, Eat Right, 3rd ed. (guidance and some specific nutrition information about American and ethnic fare)

-    Nutrition in the Fast Lane—The Fast Food Dining Guide. Franklin Publishing Inc. Indianapolis, IN, 800-634-1993 or here. (Updated annually)

Invest a few hours upfront to gather accurate carb counts for the foods and meals you eat regularly. Turn your wild-ass-guesses into educated guestimates to improve your carb counting accuracy and, in turn, blood glucose control.

****

Hope is not only a dietitian and diabetes educator, but also a freelance writer and the author of several best-selling diabetes and nutrition books published by the American Diabetes Association and other publishers. Learn more about Hope and her publications at www.hopewarshaw.com.

Birdie is one of my favorite fellow D-bloggers. Her colorful images and sincere words are always worth a double-take. She recently compiled a coffee table book that will evoke the same reaction from your party guests — or anyone you know living with illness.

A Guest Post by Birdie B, creator of Aiming for Grace

I’m feeling a lot better lately. I’ve had diabetes for 22+ years and rather than feeling like things are getting worse, I’m feeling the best I’ve ever felt since I was diagnosed. What’s made the difference, you might ask. What’s contributed to this deeper sense of well-being and health? Is it a new medication, a new approach to nutrition and blood sugar control, or perhaps a new medical device that’s freed me from the unending testing and insulin delivery of the past?

No, what’s actually brought about this change is blogging of all things.

Prior to the advent of blogging the options for coping with the unrelenting physical and psychological rigors of diabetes were limited. Once it came to be though, almost overnight and most definitely under the medical radar, people with diabetes started to talk, share and reflect their experiences back to each other. A conversation between us began, from the inside of this experience out. We’d express our feelings of the moment and then send them out into the night. And then something miraculous happened. Back from the dark came a response, a word of wisdom or understanding, a much needed encouragement, a friendly show of support. Amazingly, someone who really knew what we were talking about was listening. We found solace and comfort because of this. We found solidarity and community to assuage our loneliness and isolation. We even found new techniques and helpful ideas to use in our own diabetes management.

Through blogging we found our voices, on our own terms, as both individuals and a community living with this disease. We found a place of healing and a safe forum to express our grief and frustrations, fears and despair as well as our humor and hope and pride. Blogging, in a very real way, created a place that allows us to experience integration, wholeness and peace in who we really are. And best of all, we don’t have to visit all the time, though whenever we do need to, it’s there for us, 24/7. And knowing that helps us get on with the living of our lives more fully.

For me personally, blogging has literally changed how I inhabit my life diabetes. I never planned for this to happen but thankfully it has. Where before I felt deeply lonely and isolated because of my experience, I now feel seen and understood. Where before I felt burdened and heavy because of diabetes, I now feel buoyed up and supported. Where before I felt weak and frightened, I now feel a part of a community of courage and grace, a community dealing with similar challenges that I face.

Blogging has helped me develop a philosophical approach to my disease that’s led to a new found equilibrium between my internal diabetic experience and my external life in a non-diabetic world. In a very real sense, blogging has brought me to a place where I have become more whole.

And that’s why I’m feeling so much better these days.

****

Do check out Birdie’s book here.

As you may know, I’m a huge fan of Theresa Garnero: diabetes educator extraordinaire and talented artist with a funny bone for diabetes. Read all about her in my recent interview.

A Guest Post by Theresa Garnero, accomplished diabetes nurse educator, author and cartoonist

What does your diabetes educator really think about your diabetes?

Is it all about your quarterly diabetes report card-your A1C less than 7, blood pressure less than 130/80, and LDL less than 70? Hopefully not. From my perspective, it goes beyond these important numbers we struggle to achieve.

The diabetes profession focuses on the “A, B, Cs” (A1C, blood pressure and cholesterol) because when in target, they help to prevent complications. If one person can avoid issues associated with diabetes gone wrong, the enormous impact on their life, and the lives of their family and community is immeasurable. Focusing primarily on these desired outcomes, however well intentioned, may risk alienating the very people we are trying to help. What happens when your A1C is high? Do you feel you have failed or worse, feel blamed for it? How does that impact what you do next?

Diabetes control is somewhat of an oxymoron and a never-ending moving target. It is not magic; it is hard work. The time you invest in yourself in attempting to control this disease is time well spent. You are in this for the long haul, so pace yourself and take things in stride. It’s the small diabetes action items that allow you to achieve the desired numbers.

My approach is to emphasize the process of how people get to their destination of diabetes control and the importance of adding perspective through humorous anecdotes discovered along the way.

Are you actively involved in pursuing ways to manage your disease? When people are in touch, or make the connection of what works in their lives and what doesn’t - that’s how I measure a win. Success comes in many shapes and forms. Check out these recent examples:

• Being really pissed off about having diabetes.
• Telling the waiter, “I’ll have the salmon and please cut the rice in half-look, I’m a diabetic!”
• “What do I want out of this class? I want out of this class!”
• “Staying active is the only way to stay active.”
• “I’ve lost 200 pounds-just the same 10 pounds over and over again.”
• “Insulin is a gift.”
• The person who lost 50 pounds by asking himself “Am I satisfied or stuffed?” at every meal.
• “I was diagnosed a few desserts and margaritas ago.”
• “It doesn’t pay to be negligent.”
• “The sweeter it is, the smaller the portion.”
• “Diabetes is invisible.”
• “Who knew veggies could taste so good?”
• “I saw my eye doctor.”
• “I took a brisk walk 5 days last week.”
• “My numbers are high at work.”
• “One slice of pizza with a large salad only brings my sugar up 40 points.”
• Being consistent with taking medications.
• Sharing why medications were not taken (side effects, expense, forgot).
• Bringing a spouse to an appointment.
• Returning with the annoying food and activity records completed so we have information to help.

The next time you get your diabetes report card, add a column for effort. If you are trying your best, give yourself an “A” and pat yourself on the back. Only you know what it is like to live with diabetes, and hopefully your friends, family and diabetes care team cheer you on.

I think the decisions you make along your diabetes journey and your level of determination to take advantage of opportunities to improve your health are as important as the standard measurements used to refine your level of success.

****

Theresa Garnero’s books and “fun pancreas” products are available online here. For more about her and her work with diabetes cartoons, visit her main web site here.