Besides food safety, what does kitchen organization have to do with nutrition? An organized kitchen is a more inviting space. If you like being in your kitchen, you're more likely to use it! And eating at home usually means healthier meals. Just consider that the average person eats about 134 calories more a meal when eating out.

Ready to get your kitchen whipped into shape? Try these tips:

De-clutter. Get rid of old or expired food items. Throw out or recycle kitchen utensils that are broken, never used or duplicates.Organize by function. Group like items together. For example, put breakfast items all on one shelf, and baking items on another.Set the stage. Put pots and pans near the stove, dishes near the sink or dishwasher, and herbs and spices near the food prep area. Go vertical. All out of cupboard, drawer or countertop space? Invest in hooks or other hardware to hang up your pots, pans, utensils and aprons.Beautify. Kitchen organization can be attractive as well as functional. Use ceramic bowls or decorative baskets to hold fruits and vegetables or napkins and dish towels.

Don't overwhelm yourself by taking on the whole kitchen. Give yourself 30 minutes and see what happens. That 30 minutes might inspire you to tackle another cupboard or even your freezer next. Rediscover the joys of being in the kitchen. Make a meal and savor it — and your space.

- Katherine

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Are you considering the use of an insulin pump? More and more people with type 1 diabetes and insulin-dependent type 2 diabetes are wearing insulin pumps. Insulin pumps deliver rapid-acting insulin 24 hours a day.

Insulin pumps deliver insulin in three ways:

Basal rate. The insulin pump delivers small hourly increments of rapid- or short-acting insulin over a 24-hour period. The basal rate replaces a long-acting insulin injection and accounts for approximately 50 percent of a person's total daily insulin requirement. Boluses. These insulin injections are required to cover carbohydrates eaten at meals.Correction. A correction is used to adjust the pre-meal insulin bolus for glucose values outside of the blood glucose target range.

Benefits of insulin pumps
Insulin pumps can:

Improve blood glucose control by delivering individualized basal ratesEliminate inconvenience of multiple daily injectionsIncrease lifestyle conveniences — you have more flexibility about when and what you eatOffer precise dosage delivery in basal rates as low as 0.025 units per hour and bolus rates of 0.1 unit dosesAllow temporary basal rates Deliver a special meal bolus to match the delays in the absorption of certain foodsUsually result in fewer large swings in your blood glucose levelsReduce frequency of hypoglycemia

Disadvantages of insulin pumps
On the flip side, an insulin pump:

Can malfunction, delivering too much or too little insulinIncreases risk of diabetes ketoacidosis — the pump uses only rapid-acting insulin, and if insulin delivery is disrupted for any reason, your blood glucose will rise rapidly putting you at risk of ketoacidosisMay be expensive — costing around $7000 for the pump itself, with supplies costing about $1500 a yearIs attached to you all day every dayWon't take care of all your blood glucose problems — you'll still need to test your blood sugar before meals and at bedtime, and the person using the insulin pump will continue to give a bolus before meals

Most insulin pump users would agree that the advantages far outweigh the disadvantages. My two sons with diabetes both use insulin pumps and wouldn't have it any other way. If you're considering an insulin pump, you must currently be on a multiple daily insulin dose program, be experienced in carbohydrate counting, and test your blood sugar at least four times a day. A good candidate for an insulin pump must also be able to understand and work with mechanical devices or computers. Please discuss with your diabetes care team if insulin pumps interest you.

Peggy

Everyone can benefit by paying more attention to choosing healthy foods, right?

For the most part, yes. However, a small number of people seem to become obsessed with the "perfect diet." These individuals fixate on eating foods that make them feel pure and healthy — to the extent that they avoid foods with any: 

Artificial colors, flavors or preservativesPesticides, genetic modificationUnhealthy fat, sugar or added salt

For some people with orthorexia:

Preparation techniques must result in "clean food," meaning it's been washed multiple times, cooked to ensure no bacteria and minimally handled.Eating out is out of the question because it's important to avoid food that they don't buy and prepare.

The term "orthorexia" has been used to describe this disorder. It comes from the Greek words "orthos," meaning straight or proper, and "orexia," meaning appetite. According to experts including Dr. Steven Bratman, the doctor who first described and named this disorder, what tips the balance from being committed to healthy eating and having orthorexia is the extreme limitation and obsession in food selection. Orthorexics find themselves being unable to take part in everyday activities. They isolate themselves and often become intolerant of other people's views about food and health.

Studies have looked to at whether this disorder is more common in groups more likely to have a keen interest in a healthy diet, such as medical residents, dietitians, students in nutrition, fitness club members and those in the performing arts (ballet, symphony orchestra and opera singers). Each of the professions studied showed some incidence. However, the studies were unable to determine if the incidence was higher than that in the general population.

Health professionals have proposed that orthorexia be officially recognized as a new mental disorder. Currently it remains controversial and grouped with other not yet accepted disorders such as night eating syndrome, muscle dysmorphia (obsession with muscle building) and emetophobia (constant fear of vomiting).

Whether it's recognized as a true medical problem or not is beside the point. It's important to seek professional help when striving for a healthy diet becomes an overwhelming drive that takes over. Orthorexia that features obsessive compulsive behaviors can be effectively treated with medication and cognitive behavioral therapy by a trained therapist.

blog index References Bartrina JA. Orthorexia or when a healthy diet becomes an obsession. ALAN. 2007;57(4):313.What is orthorexia? Journal of the American Dietetic Association. 2005;105(10):1510.Bosi ATB, Derya C, Guler C. Prevalence of orthorexia nervosa in resident medical doctors in the faculty of medicine. Appetite. 2007;49(3): 661.Kinzel JF, et al. Orthorexia nervosa in dietitians. Psychotherapy and Psychosomatics. 2006;76(6):395.Korinth A, et al. Eating behaviour and eating disorders in students of nutrition sciences. Public health Nutrition. 13(1): 32-37. 2009.Eriksson L, et al. Social physique anxiety and sociocultural attitudes toward appearance impact on orthorexia test in fitness participants. Scandinavian Journal of Medicine and Science in Sports. 2008;18(3):389.Aksoydan E, et al. Prevalence of orthorexia nervosa among Turkish performance artists. Eating and Weight disorders-Studies on Anorexia, Bulimia and Obesity. 2009;14(1):33.Vandereycken W. Media hype, diagnostic fad or genuine disorder? Professionals' opinions about night eating syndrome, orthorexia, muscle dysmorphia, and emetophobia. Eating Disorders. 2011;19(2):145.

Summer has arrived for many of us, and summer makes me think of travel and camping trips. Traveling with diabetes requires a little advance planning. Preparation depends on where you're going and what you're doing. The American Diabetes Association (ADA) provides some good travel trips that I'd like to share:

See your doctor before leaving

Ensure good blood sugar control. If your blood sugars aren't well controlled, allow enough time before your trip to improve control before you leave. I'd also recommend seeing a certified diabetes educator, if possible, for help.Get a letter and prescription from your doctor. Ask for a letter and a prescription with a list of your medications for diabetes pills or insulin shots. The prescription will cover you if you run out or lose your insulin or medications while away. However, in the United States, prescription laws may vary from state to state. When my son forgot his insulin, we went to a pharmacy from the same chain that he usually gets his prescriptions from and he was able to get a vial of insulin. Prescription laws may be different if you're traveling abroad. The ADA recommends that you write for a list of International Diabetes Federation groups — see www.idf.org.

Prepare for an emergency abroad

Know how to find a doctor. You can get a list of English-speaking foreign doctors from the International Association for Medical Assistance to Travelers — see www.iamat.org, or call 716-754-4883. If you have an emergency while traveling and you don't have a list with you, you can contact the American Consulate, American Express, or local medical schools for a list of doctors.Wear a medical I.D. bracelet or necklace. It's important to wear identification that states that you have diabetes. It could also be helpful to know how to say "I have diabetes" and "Sugar or orange juice please" in the language of the country you'll be visiting.

Pack extras

Pack extra medication and insulin. Aim for at least twice as much as you think you'll need. Keep your medication and insulin with you in a carry-on bag, because checked luggage can be lost.Keep snacks available. Bring well-wrapped, air-tight snacks such as crackers, cheese, peanut butter, fruit, and some form of sugar, such as hard candy or glucose tablets, to treat low blood glucose.Protect supplies from heat. Insulin stored in very hot or very cold temperatures may lose strength. So, don't leave your insulin in the car. Meters and supplies are also sensitive to extreme temperatures. If you're camping or backpacking, consider storing insulin or meter supplies in a cooling pack made specifically for diabetes supplies.

Understand potential insulin issues

Try to use the same insulin. Stick with the exact brand and formulation of insulin as prescribed by your provider. But if you run out while you're on the road and you're unable to fill your prescription for some reason, you can buy NPH or regular insulin over the counter in the United States. Contact a physician for equivalent doses. You can discuss this with your physician before leaving for your trip.Be aware of differences abroad. In the United States, insulin is usually sold as U-100 (100 units of insulin per mL). Outside the United States, insulin may come as U-40 (40 units of insulin per mL) or U-80 (80 units of insulin per mL). If you need to use these types of insulin, you must buy new syringes to match the new insulin. When my son had emergency surgery for an appendectomy in Ukraine, he was allowed to use his own insulin. Adjust for time zone changes. If you're crossing several time zones, talk to your doctor or a certified diabetes educator to help you plan the timing of your injections. Bring along your flight schedule and information about the time zone changes. Note that if you need to inject insulin during a flight, be careful not to inject air into the insulin bottle. In the pressurized cabin, pressure differences can cause the plunger to "fight you."

Take care once you're there

Monitor your blood glucose more often. Jet lag may make it hard to tell if you have high or low blood sugar.Carry hypoglycemia treatment. If you're more active than usual, your glucose may go too low. Carry along snacks if there's a possibility that meals will be delayed or missed.Be careful about what you eat. Avoid tap water overseas, and ask for a list of ingredients in unfamiliar foods.Protect your feet. Wear comfortable shoes, and check your feet daily for blisters, cuts, redness, swelling and scratches. I talked to a man who'd hiked in the Arizona desert for several hours; when he got home, he saw blood on his socks. A cactus needle had pierced through his shoe and wedged a quarter-inch into his foot! Because he had peripheral neuropathy, he hadn't felt it.

Lastly, it can be helpful to prepare for airport security if you're flying to your destination. Check the ADA's webpage on air travel and diabetes for more information about how security measures may affect you — www.diabetes.org.

Happy travels!

Peggy

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A new school year means new challenges, but packing your children's lunch boxes needn't be one of them. Use these tips to create healthy, kid-friendly lunches.

Be smart about food safety. Stave off food-borne illness with a few common sense precautions:

Start with a warm up. If you plan to pack soup or other hot entrees, use preheated insulated containers. To preheat, just fill with boiling water and let stand a few minutes before adding the hot food. Get the Chills. Surround your perishables with chilled items. Sandwich them between cold packs. Freeze bread, water bottles, 100% juice, or yogurt tubes to keep the inside of your lunch container cold until lunch time.Made in the shade. Encourage your children to store their lunch boxes away from direct sun and any heating or cooling sources.No worries. Pack items that aren't temperature sensitive to avoid the worry of unsafe bacterial growth.  Pack small packets/cans of meat or fish and whole grain crackers for make it yourself mini sandwiches at the lunch table.  Peanut butter, bread, bagels, and wraps, fruits, and veggies are all safe bets too.

To create nutrient-packed lunches, remember to cover the basics:

Grains. Make whole-grain bread, mini bagels, pita or tortillas the basis of healthy sandwiches. Pack in a container that keeps them from being squished or crumbled and fresh tasting.Fruits and vegetables. Make fruits and veggies easy to munch by cutting them into bite-sized pieces. Choose fresh, dried or canned. Send along a small container of yogurt for dipping. Again, pay attention to packing to protect food from unappetizing bruises. Protein. The standard PBJ is a great choice. If food allergies nix peanut butter, explore other protein-rich spreads for sandwiches. In addition to lean lunch meat, fish, beans, nuts, cheese and tofu are great protein sources for growing children.Calcium. Send milk in a thermos or let your child purchase milk at school. If you child isn't a milk drinker, pack yogurt, cheese or fortified juices — all good sources of calcium.

If sandwiches are losing their appeal, try a twist to deliver the same great nutrition:

Shape up. Cut sandwiches into fun shapes using cookie cutter to add pizzazz.Switch it up. Instead of bread, sandwich your protein, veggies or fruit between crackers, rice cakes, bagels, pita pockets or tortillas. Put in the subs. Try packing whole grain pasta or rice with sliced veggies and olives; peanut butter dip for fruit; dry cereal mixed with dried fruit and nuts, or yogurt with fruit and granola. Cube leftover chicken and pair it with grapes or bell pepper chunks on a toothpick for a tower of fun.Containers and more.  Kids begging for those pre-packed lunches they see ads on TV? Do it yourself with fun multi pocket containers — sliced cheese, pita pocket squares, cut up fruit or veggies. Got an eco conscious kiddo? Pack items in reusable sandwich bags in fun, fashionable prints for girls and guys.

Brighten your child's day by writing a note and stashing it the lunch box. Or go all out and use a small amount of food coloring to "stamp" your child's sandwich with a secret code or symbol.

I've got you started. Now I'm going to call on you. What do you do to ensure that lunch boxes come home empty — and not because the healthy food you packed got thrown away?

Here's to a great school year,

Katherine

blog index References Keeping bag lunches safe. U.S. Department of Agriculture. http://www.fsis.usda.gov/PDF/Keeping_Bag_Lunches_Safe.pdf. Accessed 8/31/2011

Throughout my years as a diabetes educator, I've seen many people faced with the shock of a new diabetes diagnosis. There's the diabetes diagnosis itself, and then being thrown immediately into the required management of the disease. Everyone processes and reacts to this information differently. Unfortunately, the disease generally doesn't allow much time to ease into its management — scheduling and giving medications and injections, counting carbohydrates, storing insulin, understanding hypoglycemia and its treatment, using blood glucose meters, foot care, exercise and much more.

People's response to a new diabetes diagnosis varies. It's natural to respond with shock and stress. You might feel dazed or agitated, have poor concentration or a narrowing of attention, have difficulty comprehending information, anxiety, panic, a rapid heart beat, sweating, and shakiness and flushing. Some statements I've heard include:

Honestly? I wasn't expecting it, I don't eat sugar.No one in my family has diabetes.I ate a bunch of candy yesterday. That's why my sugar is high.Test my blood sugar again, I don't think it's right.I can never eat cake again.I'm not overweight. How did I get this?

People are frequently told they have diabetes, then rushed into a quick education session to learn how to test blood glucose, take the medications and insulin required, modify their diet and treat low blood sugar. These quick educations sessions aren't ideal. They may happen because of lack of time, at a patient's or physician's request, or because a person doesn't have insurance. I've looked at a person sitting there in shock and wondered how much of the information he or she really absorbed. This isn't my preferred method of education, but people amaze me sometimes at how well they adapt to it.

Studies show that after three days, adults only remember 10 percent of what they read, 20 percent of what they hear, and 30 percent of what they see. However, when adults are actively involved in learning new material, they'll remember up to 90 percent of what they say and do. So, the more active a role you can play in your diabetes education, the better.

What was your reaction to first being told "You have diabetes?"

Have a good week,

Nancy

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Is weight gain with age inevitable? It can seem that way when your weight climbs despite dieting and even exercising. Indeed, a recent study suggests that a range of lifestyle choices — not just the number of calories in your diet — influence your weight as you age.

The study included more than 100,000 men and women who were in good health and not obese. Their weight, diet and lifestyle habits were tracked for up to 20 years. The pounds seemed to creep on, with an average weight gain of slightly less than 2 pounds every 4 years.

What surprised researchers was that specific foods were independently associated with more weight gain:

Potato chipsPotatoes Unprocessed red meatsProcessed meats

On the other hand, eating more of some foods — vegetables, nuts, fruits and whole grains — was associated with less weight gain.

Liquid calories were another culprit. Alcoholic beverages and fruit juices were associated with a small but gradual increase in weight. Sugar-sweetened beverages were a major contributor to weight gain.

Lifestyle factors also influenced weight gain. Not surprisingly, physical activity was important to weight control. So was limiting TV time. Sleep also factored in. Weight gain was lowest among people who slept 6 to 8 hours a night and was higher among those who slept less than 6 hours or more than 8 hours.

Do any of these findings surprise you? Motivate you to change your habits? If so, how?

To your health,

Katherine

blog index References Mozaffarian D, et al. Changes in diet and lifestyle and long term weight gain in women and men. N Engl J Med. 2011;364:2392.

I'd like to respond to some of the feedback we've been receiving about the topic of carbohydrates and their place in your diet. I'm not a dietitian, so I've consulted with Jennifer Nelson, M.S., R.D., a Mayo Clinic dietitian, who says, "The American Diabetes Association generally recommends that around 50 percent of the calories in your diet come from carbohydrates — preferably healthy carbohydrates such as vegetables, whole grains and fresh fruit. Lean proteins or fat-free dairy and healthy fats should make up the rest of the calories."

The Dr. Bernstein diet, which has been mentioned in some comments, is low-carbohydrate and calorie restrictive. In some cases, it proposes limiting calories to 800 to 1350 a day. The program also includes behavior modification, education and vitamins and mineral supplements. People with diabetes who follow the Dr. Bernstein diet are required to do intensive management of their diabetes, including blood glucose testing five to eight times a day. The main function of Dr. Bernstein's diet for those who have diabetes is to maintain constant, near-normal blood glucose levels — desirable for anyone with diabetes. Good glucose control can reduce or prevent the chronic complications of diabetes such as nerve damage, kidney damage, eye disease and heart disease risks.

When carbohydrates are reduced, you must make up the difference in fat and proteins. Consuming total daily calories at an amount needed to maintain a healthy weight is key and, over the long run, is probably more important than diet composition.

Can good glucose control be achieved on a traditional diet? It most certainly can. Good glucose control involves paying close attention to the balancing act of healthy eating, insulin use (and diabetes medications, if required), exercise and blood glucose monitoring.

Good diabetes management takes self-direction and work, no matter how it's achieved.

According to Jennifer Nelson, M.S., R.D., "The bottom line is to find a healthy eating plan that works for you lifelong."

Thanks, Jennifer. And, I hope you all have a good week.

Regards,
Nancy

With summer arriving in Minnesota and many other places, I'd like to talk about how to manage insulin storage in extreme temperatures such as this season brings.

A number of years ago, I met with a client who used a rapid insulin pen for meal dosing. She shared with me a story of how she attended the county fair on an exceptionally hot day, and had placed her insulin pen in the back pocket of tight jeans and walked around the fairgrounds all day. She used the pen for covering meals eaten at the fair, and her blood sugars were running higher than normal, but she related this to all the junk food. The next day her blood sugars continued to run high and when she took her (rapid) insulin, it didn't seem to affect her blood sugar level at all; in fact, it was like she was taking water instead of insulin. She wondered if the heat had affected her insulin, so she switched to a new insulin (disposable) pen, and soon after her blood sugars started to drop.

Has this or something similar happened to you?

I looked at insulin manufacturers' websites and found that for the majority of all types and brands of insulin, the maximum temperatures recommended are as follows:

Opened room temperature insulin should not exceed 86 F (30 C) with the exception of Lantus, which should not exceed 77 F (25 C). Most manufacturers of insulin recommend discarding insulin if it exceeds 98.6 F (37 C).

Other non insulin diabetic injectable medications:

Glucagon and Byetta should not exceed 77 F (25 C).Symlin should not exceed 86 F (30 C).

Avoiding potential problems

Temperatures exceeding manufacturer's recommendations for insulin/medications

Store your insulin in the refrigerator, in an insulated case or cooler with a freezable gel pack, or use a cooling wallet. Cooling wallets are available through many diabetes supply companies and keep insulin vials, pens and pumps cool at a safe temperature without the need for refrigeration or ice. The wallets have a liner filled with crystals. The liner is immersed in cold water for 10-15 minutes, and placed back into the wallet, along with the insulin. It works by relying on the process of evaporation for cooling, can keep insulin cool for up to 48 hours, and is reusable.

Remember, after opening a vial of insulin or starting a new insulin pen, the insulin loses its potency and should be thrown away after a certain number of days, depending on the manufacturer's guidelines. Generally, most vials of insulin are good for 28 days after opening with the exception of Levemir (detemir), which is good for 42 days. Other pens are good for 10, 14, 28 or 42 days. Check the medication insert.

Avoid temperature extremes
Never freeze insulin or expose it to extremely hot temperatures or direct sunlight. Never leave it in your car. Never place it directly on ice or an ice pack. Watch for changes in insulin appearance
Throw away insulin that is discolored or contains solid particles.

What about insulin pumps?
Heat can make proteins like insulin harden, which increases the potential for infusion set occlusions (blockage). If you live in a hot climate and especially if you work outdoors, you may need to pay closer attention to how the heat can affect your insulin. A patient of mine, who is a roofer in Arizona, found that he needed to replace the insulin in his pump reservoir daily to avoid having high blood glucose readings. Using a pump wallet could be another option for people concerned about the effects of heat on their insulin. Also, make sure that the infusion set tubing is tucked in your clothing and not hanging out and exposed to the light and or heat.

Please share your stories.

Have a great week,

Nancy

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As surprising as it may sound, a normal weight or normal body mass index (BMI) isn't a guarantee of good health.

Someone who has a BMI in the acceptable range may still have an unacceptably high percentage of body fat. This is called normal weight obesity. Too much fat tissue puts you at risk of cardiovascular disease and metabolic syndrome, associated with type 2 diabetes, among other chronic diseases.

You may be thinking, "Oh great, one more thing to worry about." But look at this way: If you're working at maintaining or losing weight, you're already on the right track. A healthy diet and exercise are exactly what you need to do to control not only your weight but also your body fat percentage.

If you aren't eating a balanced diet or getting any exercise, you may want to talk with your doctor about adopting a healthier lifestyle. Your scale may not suggest it, but your heart will thank you.

To your health,

Katherine

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Although America provides some of the world's best health care and spent over $2.5 trillion for health in 2009, it still ranks below many countries in life expectancy, infant mortality and other key health indicators. For this reason, the U.S. Surgeon General and multiple federal agencies came together to create the National Prevention and Health Promotion Strategy, which was released in June of this year. The strategy calls on leaders in state and local communities, businesses, nonprofit groups and individuals to commit to healthy initiatives.

It's no surprise that healthy eating is one of the priority initiatives. We know that eating healthy can reduce risk of the most common, deadly medical problems including heart disease, high blood pressure, diabetes, osteoporosis and several types of cancer — many related to obesity. Eating healthy requires more than providing people with information — it needs to be supported by an infrastructure that makes healthy foods available, affordable and safe.

In keeping with the current economic atmosphere, the strategy includes no new funding and very few mandates. Here are examples of how it's supposed to work.

The federal government will:

Ensure that foods in federal programs (like school lunches) meet the standards set in the 2010 Dietary Guidelines for Americans.Improve agricultural and food safety policies to align with the dietary guidelines.Develop voluntary guidelines for foods marketed to children (for example in TV commercials), monitor and report on industry activities.

State and local governments will:

Use grants and zoning to attract full-service grocery stores and farmers markets to underserved areas, aka "food deserts."Discourage businesses that serve unhealthy foods around schools.

Schools, businesses and employers will:

Make healthy options and appropriate portion sizes the norm.Reduce sodium, saturated fats and added sugars in the foods served.Eliminate high-calorie, low-nutrition drinks and provide greater access to water.

Health care systems, insurers and health care providers will:

Assess dietary patterns (quality and quantity of food eaten) and provide appropriate care for obesity.

Communities and individuals will:

Lead and expand programs such as community gardens that bring healthy, locally grown foods to schools and businesses.Eat less by avoiding oversized portions.Exercise more.

What changes are you seeing happen that support healthy eating — in your community? In your health system? At work or in your schools? In your local and state governments? What are you doing?

To your health,

Jennifer

blog index References The National Prevention Strategy: America's Plan for Better Health and Wellness. http://www.healthcare.gov/center/councils/nphpphc/strategy/report.pdf. Accessed July 25, 2011.

Hi fellow bloggers,

Last week I shared with you a patient story about "hypoglycemia unawareness" — a condition in which a person with diabetes doesn't experience the usual warning symptoms of hypoglycemia. This week I'd like to share some risk factors and possible treatment strategies for such hypoglycemia unawareness.

Long-standing type 1 diabetes. Reduced awareness of hypoglycemia is common among people who have long-standing insulin-dependent diabetes. Many of those who've had diagnosed diabetes for 15 to 20 years report having lost their ability to perceive low blood glucoses and to often failing to treat and prevent severe hypoglycemia.

Severe hypoglycemia is an episode in which the person with diabetes is unable to treat him or herself and needs the assistance of another person. This includes prompting by a relative or friend to drink juice or eat.

Being an older adult and having type 2 diabetes. There also have been an increasing number of hypoglycemia unawareness episodes in those with type 2 diabetes; adults older than 65 seem to be most at risk.

Strict avoidance of hypoglycemia. Strict avoidance of hypoglycemia for several weeks to months can restore at least partial awareness of warning symptoms. Strategies for avoiding hypoglycemia when you have hypoglycemia unawareness or don't experience the warning symptoms include:

Aim for a higher blood glucose targetTry to more accurately count carbohydratesAvoid overcorrection or stacking of insulin dosesTest your blood glucose and adjust your insulin dose more frequentlyConsider blood glucose awareness training education programs to help you learn to identify new symptoms and improve recognitionConsider a personal continuous glucose monitor (CGM) that sounds an alarm when your glucose gets too lowConsider a service dog that can recognize low blood glucose

Glucagon for emergencies. Glucagon is the treatment of choice if someone with diabetes is unconscious or unable to swallow. The length of time a person is unconscious, is more of a concern than how low the blood glucose number is.

Ask your health care provider for a prescription for Glucagon or GlucaGen and for instructions on how to use it. Instruct your family members or friends on how to use this in an emergency and on how to access the emergency response team, such as calling "911."

Have you lost any awareness of symptoms of low blood glucose? How have you coped?

Regards, and have a good week.

Nancy

I just got a phone call from a retired Mayo Clinic doctor asking why we don't have a gallbladder removal diet. He went on to explain that he'd had a very uncomfortable and embarrassing incident after eating a large meal that contained lots of fat. My response was that there isn't a set diet people should follow after gallbladder removal because the guidelines depend on the individual.

It's helpful to know a little background: The gallbladder collects bile, a fluid that is produced by the liver, and releases it when you eat to aid the breakdown and absorption of fat. Between meals, bile collects in the gallbladder and is concentrated. When the gallbladder is removed, bile is less concentrated and it drains continuously into the intestine. This affects digestion of fat and fat-soluble vitamins. How much of a problem it is varies from person to person. With time, the body often adjusts and becomes better at digesting fatty foods.

The amount of fat eaten at one time also factors into the equation. Smaller amounts of fat are easier to digest. On the other hand, large amounts can remain undigested and cause gas, bloating and diarrhea.

Although I don't have a specific gallbladder removal diet to recommend, I can offer general advice for avoiding problems after you've had your gallbladder removed:

Eat smaller, more frequent meals. This may ensure a better mix with available bile. Include small amounts of lean protein, such as poultry, fish and nonfat dairy, at every meal, along with vegetables, fruit and whole grains.Go easy on fat. Avoid high-fat foods, fried and greasy foods, and fatty sauces and gravies. Instead, choose nonfat or low-fat foods. Read labels and look for foods with 3 grams of fat or less a serving.Gradually increase the fiber in your diet. This can help normalize bowel movements by reducing incidents of diarrhea or constipation. However, it can also make gas and cramping worse. The best approach is to slowly increase the amount of fiber in your diet over a period of weeks.Be aware that after gallbladder surgery some people find that the following are difficult to digest: caffeinated beverages and dairy products.

Talk with your doctor if your symptoms are severe, don't diminish, continue over time or if you lose weight and become weak.

I'd like to hear from anyone who has had gallbladder surgery — do you have problems — or are you able to eat almost everything? Any advice you can share?

- Jennifer

blog index References Barrett K. Gastrointestinal Physiology. http://www.accessmedicine.com/content.aspx?aID=2306279&searchStr=gallbladder#2306279. Accessed July 6, 2011.Nutrition Care Manual: Gallbladder disease process and meal plan. American Dietetic Association. http://nutritioncaremanual.org/content.cfm?ncm_content_id=81517 Accessed July 6, 2011.Fisher M, et al. Diarrhoea after laparoscopic cholecystectomy: Incidence and main determinants. ANZ Journal of Surgery. 2008;78: 482.Surawicz CM. Mechanisms of diarrhea. Current Gastroenterology Reports. 2010;12:  236.

I think change gets harder with age. I cringe inside when I find out I'm going to have to change the way I've been doing something at work and learn a new way, for example. It seems the only thing we can be certain about with change is that it will happen again. Health care behaviors seem to be some of the hardest changes to make.

A number of theories about human behavior and change exist. One such theory, by Kurt Lewin and Edgar Schein, proposes that change is a three-stage process — unfreezing a behavior, changing, and then refreezing the new behavior.

Getting motivated: Unfreezing
The first stage — the unfreezing stage — is becoming motivated to change. How do we become motivated to change? A new diagnosis of diabetes, a poor A1C report from the medical care provider, nudges from a family member or self-evaluation all might motivate change. At this stage, the change process becomes a mental game of mind over matter. We realize the current situation isn't working and that ignoring the condition won't make things better. Real and unreal anxieties can slow down and impede the process of change. You might question if you can change, how to start or if it will make a difference.

Making changes
The change stage follows making the decision that a change needs to occur. Next, we must decide what needs to change. Activities that help us change are beneficial in the change stage. These activities might include:

Choosing a specific behavior you want to work on changing Being realistic — avoid trying to change everything at onceWriting down the change and posting it in plain sight to give yourself a daily reminderDiscussing the change with others around you and asking for their support and encouragementFinding a support groupSeeing your diabetes health care team regularlyChanging your environment to support your change, such as getting snacks out of the home

Making it permanent: Refreezing
The refreezing stage — making the change permanent — is probably the hardest stage. This final stage is when the change becomes habitual and includes developing a new self-concept. You become a person identifying and living for wellness.

Your thoughts?

Have a great week!
Nancy

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For those of you with depression who've been struggling to find the right antidepressant medication, the introduction of a new antidepressant is always a hopeful event. Recently, the antidepressant vilazodone became available to U.S. patients. The trade name of this new medication is Viibryd.

National Suicide Prevention Lifeline
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The mechanism action of vilazodone is somewhat different from many antidepressants. While vilazodone does inhibit the reuptake of serotonin like so many other antidepressants, it's also a "partial agonist" of the serotonin 1A receptor. This second mechanism may be particularly helpful for some people based on the receptivity of their serotonin 1A receptor.

It's not clear who will be most likely to respond well to vilazodone as a result of its effect on the serotonin 1A receptor. However, future research focusing on differential response may well lead to clues that will help us identify who will respond to vilazodone.

The metabolic profile of vilazodone makes it quite likely that most people will be able to tolerate it at the recommended dose. However, since vilazodone is metabolized by the cytochrome P450 3A4 enzyme, a small number of people who have deficient copies of the gene that codes for this enzyme are unlikely to tolerate vilazodone at the standard dose. This problem with tolerance will also be true for people who have a normal metabolic capacity, but who take medications that inhibit the function of the 3A4 enzyme.

One of the most attractive aspects of this newly released antidepressant is that the initial clinical trials reported a quite low incidence of sexual side effects. If these initial reports are confirmed as larger numbers of people are treated, vilazodone will clearly become the antidepressant of choice for those who have struggled with sexual side effects while taking either the SSRI's or the SNRI's.

At this point, there's been little pharmacogenomic research focused on this new drug. However, as individualized molecular psychiatry becomes more prominently practiced, future research will hopefully provide some clues as to which of you will be most likely to respond to vilazodone.

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If you have diabetes and use insulin, consider wearing a medical I.D. bracelet (medical identification bracelet). No one plans to have a medical emergency, but it's a good idea to be prepared for one.

Medical I.D. bracelets are an excellent way to expedite treatment and avoid misdiagnosis during an emergency. Paramedics are trained to look for medical I.D. bracelets.

Both high and low blood sugar can lead to unconsciousness, coma, seizures and death. If emergency care personnel need to look through your wallet or purse for a medical I.D., treatment may be delayed. And if a person is behaving oddly or has lost consciousness, bystanders are more likely to call for help if they recognize that the problem is medical, rather than related to drugs or alcohol.

Medical I.D. bracelets don't have to be ugly. Many attractive medical I.D. bracelet options exist. Check at your local pharmacy, or do an online search for medical I.D. bracelets. You might be surprised by your options!

Peggy

In recent blog entries, we've discussed research that's linked gene variations with medications in order to determine if they'll be safe and effective for individuals with depression.

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The study of these relationships is referred to as psychiatric pharmacogenomics. These aren't tests to determine whether someone is depressed or not. As some of you pointed out, after years of suffering, the diagnosis of depression is not the issue.

The important new development is trying to find an effective treatment. While single genes such as the serotonin transporter gene provide us with some clues, there are still other genes that need to be discovered in order to be able to make better predictions than we can today.

In the past year, three large studies have been conducted to explore possible new genes associated with a better outcome. They include a study in England that found a gene called interleukin-2 was associated with a response to Celexa. However, studies in Germany and the United States didn't confirm this finding.

At Mayo Clinic, we're conducting a similar study to try to identify more gene variants so that we can make better predictions of response to treatment. Another goal is to find new genes that are associated with adverse effects. While many adverse effects are associated with antidepressant medications, one of the most serious is "activating" an episode of mania in someone who's previously not experienced mania.

Another major concern is that sometimes antidepressant medication seems to aggravate suicidal thoughts.  Progress is being made in using genomic testing to be able to identify who may be more likely to develop these problems.

One of the greatest motivations for finding new genes associated with medication response is that gene variation may give us new clues to help us develop new medications for depression — given that at least one in five of you with depression don't respond to any of the drugs currently available.

Helping you if you have treatment resistant depression is a critically important priority for research. Please share your thoughts.

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According to the National Eating Disorders Association, eating disorders — such as anorexia, bulimia and binge eating disorder — include extreme emotions, attitudes and behaviors surrounding weight and food issues. Eating disorders are serious emotional and physical problems that can have life-threatening consequences for females and males.

The Juvenile Diabetes Research Foundation reports that a new type of eating disorder has surfaced. Unofficially coined "diabulimia," the condition occurs when those with type 1 diabetes skip or restrict insulin use to lose weight. Type 1 diabetes is a dangerous disease if untreated. Failing to take insulin raises your blood sugar and results in frequent urination — the body's attempt to rid itself of excess sugar in the bloodstream — resulting in rapid weight loss.

According to the American Diabetes Association (ADA), researchers estimate that 10 to 20 percent of females with diabetes in their mid-teens and 30 to 40 percent of those in their late teens or young adult years skip or alter insulin doses to control their weight. Uncontrolled blood sugar can lead to long-term complications, such as heart attacks, strokes, eye problems or blindness, nerve damage in the hands and feet, kidney damage, and gum disease.

The ADA suggests that early warning signs of an eating disorder such as diabulimia in someone with diabetes include:

Very high A1C test resultsFrequent hospitalizations for diabetes ketoacidosisFrequent severe low blood sugarAnxiety or avoidance of being weighedWidely fluctuating blood sugar levels without obvious reasonDelay in puberty or sexual maturation or irregular or no mensesBinging with food or alcohol at least twice a week for 3 monthsExercising more than is necessary to stay fitSevere family stress

If you think that you or a loved one might have diabulimia or another eating disorder, please talk to your healthcare provider. It is important that you seek evaluation and treatment. Your provider can recommend a health counselor who will help you or your loved one with this problem.

Peggy

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In the July 9 New York Times, Dr. Peter Kramer wrote a piece titled, "In Defense of Antidepressants". It seems ironic that such an article is needed, given the substantial evidence that antidepressants have helped millions of people. However, there continues to be a confusing, academic argument about some of the studies of antidepressants.

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Dr. Kramer is a gifted psychiatrist. He achieved national recognition 18 years ago when he wrote the book "Listening to Prozac". He made his patients come to life for the reader. I read the book and was impressed by how many people he had helped to find their way forward by combining sensitive psychotherapy and appropriate use of one of the earliest serotonin reuptake inhibitors, Prozac.

While his recent article takes on a difficult topic, I was pleased that the paper published it. While some of the details are too esoteric for most readers to follow, the balance of evidence clearly demonstrates that antidepressants work. That's also the conclusion of the FDA and is the experience of many people who have recovered from a serious depression.

Of course, as has been discussed at great lengths on this blog, not all antidepressants work for everyone. Additionally, for some of you, the side effects can be intolerable. Despite millions of dollars of research, the process of finding the right antidepressant is still a difficult one.

While some new tools, such as pharmacogenomic testing, make this process somewhat more rational, it's clear that the search for a better antidepressant must continue and that research designed to identify which people will respond to which medication should have a high funding priority from the National Institute of Health.

One type of study that Dr. Kramer discusses is particularly interesting and rarely considered. These are "maintenance studies". In his article, Dr. Kramer refers to a large study of 4,410 patients who initially had a good response to an antidepressant. The study was designed to focus on the question of how long to continue treatment. The study also wanted to examine the possibility that some patients may respond to treatment as a consequence of other factors besides their medication.

In this study, after successful treatment, half of the patients were switched to a placebo and the remainder continued to receive their active antidepressant. The participants didn't know if they were still getting their antidepressant or had been switched to a sugar pill. In many ways, this is a tough study to volunteer to be in. However, the results were clear. About 70 percent of those who were switched to the placebo relapsed, while most who remained on their medication didn't relapse.

This finding strongly suggests that simply believing that you're taking your antidepressant is not sufficient to maintain a good response. This result makes good sense and supports the importance of staying on a medication that's working.

A link to Dr. Kramer's article can be found in the Resources tab above.

Please share your thoughts.

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This week I'd like to deviate from the human nature of diabetes and chat, instead, about our animal friends (pets) with diabetes. For the first time in my life, I have the opportunity to have a dog in my life, so I started looking at local websites for adoptable dogs. I'm looking for a medium to large adult female dog that's trained, laid back and likes children. A particular dog caught my eye. Her name is Carlie, and she's a golden retriever and Labrador mix. Carlie has diabetes and is in a foster home that's taking great care of her. Carlie was extremely overweight and has gone from 118 pounds to 75 pounds. Her foster parents have her on a special diet and exercise regimen, and she's given insulin injections twice a day. I started asking my patients about their pets. The first patient I saw today told me her dog has diabetes.

I recently did some research on pets with diabetes and found that:

Diabetes is on the rise in United States cats and dogs as they, and we, become more overweight.Overweight cats are six times more likely to develop diabetes than are thinner cats.Symptoms of diabetes in pets include excessive urination, increased thirst and weight loss.Dogs often get type 1 diabetes, and type 2 diabetes is more common in cats.Like humans, dogs properly treated for diabetes typically live a long, full life.

Right now, I have a choice whether or not to take on the management of owning a pet with diabetes, unlike those of you who have diabetes and have no choice but to cope with the daily self-management of this chronic disease. As a first time dog owner, Carlie would be quite a commitment, and I don't know if I have the time or resources to manage her properly. I want to make the right decision for me and her. I'll keep you posted on my decision.

Please share stories about your pets with diabetes, including pros and cons.

Have a great week.

Regards,

Nancy

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For some, the holidays are an especially difficult time. For others, this is a joyous time of year. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)Holiday depression — and depression in general — challenges even the most optimistic people. Although it may be difficult, promise yourself that you will commit to having a positive attitude. If you're feeling depressed during the holidays, do the following for yourself: (this will take practice)

Do the best you can. (perfection is not attainable)Give yourself the gift of positive self talk (don't repeat negative message from the past that are not true)Truly believe in yourself, including your goodness and self-worthAccept that life is not perfect. Injustices and suffering occur. It is normal at times to feel angry and to grieve. Get help on how to manage these feelings.

Depression can literally strip away self-esteem and the hope that things can get better. Depression can cause you to think in a very negative manner. But don't get discouraged. Get the help you deserve today. Share with us any tips you use on getting through holiday depression.

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Wow, what a tremendous response to the new diabetes blog. You are showing the huge impact diabetes has on an individual's life, family, community, and society as a whole.

Peggy and I would like to thank all of you for sharing your stories about living with diabetes. As you all know, diabetes is a complex issue and there are many facets involved in managing and living with the disease.

In viewing the comments, we would like to thank you for sharing your personal experiences, challenges, burdens, and successes. This is your opportunity to share information and tips, and Peggy and I plan on choosing a couple items each week to respond to.

This week I would like to talk about the blood glucose target range. What should it be? A normal fasting blood glucose target range for an individual without diabetes is 70-100 mg/dL (3.9-5.6 mmol/L). The American Diabetes Association recommends a fasting plasma glucose level of 70–130 mg/dL (3.9-7.2 mmol/L) and after meals less than 180 mg/dL (10 mmol/L).

Individuals with hypoglycemic unawareness (limited or no awareness of low blood glucose symptoms) may require a lower target range. Your healthcare provider may personalize your blood glucose target for specific medical conditions. Blood glucose targets should be in a healthy range to prevent diabetes complications, but also keep you safe from serious low blood glucoses.

Remember, blood glucose targets are targets. Diabetes is a balancing acting and blood glucoses will fluctuate; even sharpshooters don't hit the bull's-eye every time.

Once again, thank you. Keep the comments coming. We will try to address some of your concerns in the upcoming weeks.

- Nancy

We've known for awhile that some people will have a worsening of their mood in the winter. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)This is referred to as Seasonal Affective Disorder or SAD. SAD can be treated effectively with medication and/or light therapy.

A specific type of light, a full-spectrum light, is sometimes used to treat SAD. Insurance may or may not pay for the light. Not all people with depression have a seasonal worsening of mood.

Some things to keep in mind about SAD and light therapy:

The benefits of light therapy have clearly been shown in multiple studies over many yearsMost people with a diagnosis of SAD show improvement in depressive symptoms one week after starting light therapyLight therapy typically causes few side effects Light therapy requires 15 to 30 minutes per dayUse of light therapy in patients with bipolar affective disorder may destabilize the mood

Currently, researchers are looking at using light therapy to treat major depressive disorder as well as other psychiatric illnesses. Time will tell if light therapy can be used alone to treat depression or other psychiatric illnesses. As always, don't self-diagnose or self- treat; talk to your provider about your symptoms.

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Friends or family members often ask us how they can help a loved one who has diabetes to make lifestyle changes. With a husband who has type 2 diabetes and two sons who have type 1 diabetes, I know that there's a lot to learn about living well with diabetes on a personal level. Diabetes is a hard disease to handle alone.

Here are some ways that you can support your friend or loved one.

Voice your support. Let the person with diabetes know that you love them and are willing to help.Learn about diabetes. Read books and reliable websites on diabetes. And go to doctor's appointments and diabetes classes with your loved one. Talk about your feelings. Let your loved one know that his or her diabetes affects you, too.Let go. It's not your responsibility to manage another person's diabetes. Just because I'm a certified diabetes educator doesn't give me nagging rights. My family members with diabetes feel more comfortable asking for help when I'm simply available to them.

I've also found that lifestyle changes that are good for a person who has diabetes are also beneficial to the rest of the family. For example:

Exercise together. Exercise for you and your loved one with diabetes. Invite your loved one to go to the gym or for a walk with you.Choose healthy foods. Healthy meals benefit the whole family. If you have a relative with diabetes, you're at risk. Making lifestyle changes now can postpone or prevent diabetes!Encourage. Applaud your loved one's efforts and successes and encourage him or her during struggles.Be considerate. When having a party, offer healthy, tasty treats such as fresh fruit.Seek outside help. If your loved one is sad or depressed, ask your health care provider about ways to get help. Ask about a diabetes support group in your area. You can also ask to meet with a certified diabetes educator.

Being the primary caregiver for a person who has diabetes can take an emotional toll. A diabetes caregiver may be the one taking ownership of his or her loved one's diabetes if the person with diabetes doesn't or can't. If you find it's too much for you, talk with your healthcare provider or diabetes educator. Together, you can determine at what point you may need outside assistance, such as from a nurse.

Peggy

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In reading your comments, I'm struck by a number of observations:

Many of you have suffered for a long time with depression but haven't given up. Most impressively, many are trying to help others.It's common to find an antidepressant medication that works for awhile and then after some months or years, it stops working. This is extremely frustrating for you and your doctor. The truth is that we don't really understand why this happens. There are probably different reasons for different medications. Fortunately for some of you, it doesn't happen.National Suicide Prevention Lifeline
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When you're doing well on an antidepressant, it's reasonable to ask how long you should keep taking it. Unfortunately, there's no absolutely correct answer. However, most clinicians feel that as long as the medication is having a beneficial effect, it's probably wise to keep using it. This is particularly true because some of you do well on the same medication for many years.

One of the current theories for why antidepressants stop working is that over time the genes that produce enzymes that regulate the metabolism of medications become upregulated and consequently produce more enzymes. If this is the case, it may lead to a decrease in the blood level and it may be necessary to increase the dose in order to get the same effect.

Some of you decide to stop taking antidepressants when you feel better, and then find that symptoms return. At that point, you want to begin taking the medication again. For some, the medicine once again helps, but for others it doesn't seem to have the same positive effect that it initially had.

It would be helpful if you'd share your own stories related to a particular medication losing effectiveness. The personal stories might provide some clues that could help others to better understand why a particular antidepressant medication stops working. It would be important to know the name of the medication that initially worked and what events were associated with it losing its effectiveness. While it's frustrating to have a medication lose its effectiveness, usually a replacement can be found that will once again lead to some relief of depressive symptoms.

One of you asked about being an ultrarapid metabolizer. This means that for some antidepressants it would be difficult for you to achieve an adequate blood level and therefore it would be unlikely you'd have a good clinical response at a safe dose.  However, it's important to understand that even though someone is an ultrarapid metabolizer for one type of antidepressant, it's quite possible that they could be a normal metabolizer of other antidepressants. This is a critical concept for both patients and their doctors to understand.Another question was how pharmacogenomic testing can be obtained in Canada.  It's my understanding that it's available at the major academic medical centers in Canada as they have good access to major reference laboratories which all offer pharmacogenomic testing. However, I don't believe that it's routinely paid for by the Canada's national health system. Hopefully, this will change as the benefits of testing become more widely understood.blog index

This blog is in response to a reader question about the symptoms of kidney disease that we received about our blog, "With diabetes, kidney care is crucial."

In some people with diabetes, over time, high blood glucose levels can damage the millions of tiny blood vessels that filter waste from the blood and dispose of it in the urine. Unfortunately, early kidney disease has no symptoms. Generally, not until the damage is extensive do symptoms emerge.

Symptoms of advanced kidney disease include:

Swelling of ankles, feet and handsShortness of breathHigh blood pressureConfusion or difficultyPoor appetiteNausea and vomitingDry, itchy skinFatigue

To identify kidney problems early, an important part of your yearly diabetes management checkup is getting what's called a urine microalbumin test. This test measures the amount of a protein, albumin, in your urine.

When kidneys are functioning normally, they filter out only waste in your blood, excreted in your urine. Protein and other helpful substances remain in your bloodstream. When your kidneys become damaged, waste products remain in your blood, and albumin leaks into your urine.

When your kidneys are in early distress, only small amounts of albumin escape into the bloodstream. You may lose 30 to 300 milligrams (mg) of albumin a day through the urine. This condition is called microalbuminuria. In advanced stages of kidney disease, you might lose more than 300 mg of albumin a day.

The most reliable test to screen for microscopic protein in the urine is to collect the urine in a container for 24 hours. Another available test, the random microalbuminuria test, requires only a one-time sample of urine.

If your health care provider is aware of early kidney disease through such testing, early treatment measures can help prevent or slow down the progression of diabetes-related kidney disease. Treatment measures include:

Keeping blood glucose levels in a healthy target range, as determined by your doctorMaintaining a healthy blood pressure level, as determined by your doctorStarting an ACE inhibitor blood pressure medication, which has protective benefits to the kidneysEating a low-protein diet

Your comments are appreciated.

Have a great week,
Nancy

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My husband and I recently went on a road trip to Arizona for our son's wedding, and our van broke down. Fortunately, there was a motel and repairman nearby. We settled in at the motel and went through the routine of getting ready for bed. My husband — who takes two types of insulin — suddenly said, "I feel like I'm going to pass out." I immediately went into "nurse mode" and checked his pulse.

Next, I glanced at the bedside table and saw a bottle of NovoLog insulin and a used syringe. I picked up the vial and asked if he'd just given himself that insulin, and he said he had. I realized he'd accidentally given himself NovoLog — his rapid-acting insulin — instead of Lantus — the slowly released insulin. We tested his blood sugar and it was 40 mg/dl (2.2 mmol/L). We spent the next 4 hours giving him simple carbohydrates and testing his blood sugar every 10 to 15 minutes.

For many people with diabetes, injecting two types of insulin is a daily requirement. As diabetes educators, we suspect that taking the wrong insulin happens more often than is reported. Giving yourself your injections can become so much a part of your routine that you can do it without thinking — which can lead to errors. My husband learned this lesson about insulin safety the hard way. He was distracted, thinking about the van repairs we needed to get back on the road.

To increase insulin safety and avoid taking the wrong insulin:

Pause, and double-check that you're taking the correct insulin. Use a syringe for your long-acting insulin and an insulin pen for your short-acting insulin. Label insulin vials or pens with different-colored tape, so that you can differentiate between them. For example, use red tape for short-acting insulin and yellow tape for long-acting insulin.

If you accidentally give yourself the wrong insulin:

Call 911 or your local emergency number.Test your blood sugar frequently until help arrives. Eat or drink a fast-acting carbohydrate to maintain a blood sugar within your goal range.

In preparation for such issues, it's a good idea to:

Always carry a simple sugar source with you, such as glucose tablets, juice, regular soda or hard candy.Wear a diabetes medical I.D. bracelet.Carry a glucagon kit.

We'd love to hear from readers who've had similar insulin safety experiences.

Peggy

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We've all heard that doing things "in moderation" is acceptable. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)So can you drink a moderate amount of alcohol if you have depression? I don't advise it. In most cases, one should steer clear of alcohol for a number of reasons:

Potentially dangerous interactions with medications. Not just psychiatric medications and not just prescription medications, remember over-the-counter medications, too!Alcohol itself is a depressant and can make depression (and anxiety) worse.Alcohol affects one's judgment and decreases inhibitions.Alcohol has a negative impact on the quality of sleep overall.Alcohol can worsen other health problems.

Have a discussion with your health care provider regarding alcohol and depression. Certainly if you have a history of alcohol abuse, dependence, and/or have had treatment for alcohol or other drugs, please be honest with your provider. Your provider will be able to best help you when they have all the facts.

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This blog has sensitized me to how hard it is for so many of you with severe depression to find help. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)It's very clear that there's a wide range of severity of symptoms. Perhaps more importantly, there are wide variations in the responses you have to the currently available treatments.

If you begin to experience severe depression for the first time as a young adult, the prognosis is generally quite good. There's an almost 50 percent remission rate with the selection of the first medication — if it's taken properly and for a sufficient period of time. Ultimately, more than 80 percent of you will respond to one of the many available medications. However, the fact that some of you don't respond is a huge problem.

There's no simple solution for treatment resistant patients. Your best hope is to be persistent. However, it's difficult to be persistent when you're seriously depressed. It's a cruel "Catch 22."

Electroconvulsive therapy (ECT) is available for treatment resistant patients and many do respond to it. While there continues to be controversy about it, and there's no question that it can result in the loss of memory, ECT has saved the lives of many. Newer treatments, such as transcranial magnetic stimulation (TMS), offer hope. However, those who are resistant to medications may also be resistant to TMS.

Over the years, I've seen our treatments improve. I remember a world without serotonin transporter inhibitors. It was a world where our best drugs had considerable toxicity. It was also a time when we had fewer options if you were seriously depressed.

We treat thousands of people who have mood disorders. Clearly, most if them get better and many have a complete remission of their symptoms. However, it would be wrong to suggest that even in 2010 there's an effective treatment for everyone. Nevertheless, we're committed to finding new ways to try to help everyone.

There's no major medical specialty that has the ability to cure everyone they try to treat. Some people with asthma don't respond to even the newest asthma medications and have crippling wheezing which dramatically restricts their activity. Some people with diabetes can't control their glucose despite the huge advances in our understanding of the biological basis of diabetes. Perhaps most frustrating of all, many cancers continue to take the lives of our loved ones despite billions of dollars of medical research and the hard work of many medical professionals.

I don't want to suggest there's an easy answer for those of you who suffer from treatment resistant depression. However, I do want to underscore that many of you can improve with modern treatments. For those who don't, it's critical to maintain your determination to "fight the battle" even when it seems hopeless. Having friends, a family that cares, and a doctor you can trust are still among the most powerful weapons to fight depression.

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You've been told that high blood sugar causes complications, but have you ever wondered why? Diabetes often has no obvious symptoms. Occasionally, a patient tells us that maybe high blood sugar is normal for him or her. But there's no such thing as "a touch of diabetes" or having blood sugar that is "a little high."

Blood sugar actually coats red blood cells (hemoglobin), causing them to become stiff. These "sticky cells" interfere with blood circulation, causing cholesterol to build up on the inside of your blood vessels. It can take months to years for the damage to your body to appear. The fragile blood vessels in your eyes, kidneys and feet are most susceptible, so problems are usually noticed first in those areas.

Controlling high blood sugar may help prevent or decrease many long-term diabetes complications, such as:

Heart attackStrokeEye problems that can lead to trouble seeing or blindnessNerve damage in your hands and feet that can cause pain, tingling and numbnessKidney problems, including kidney failureGum disease and tooth loss

Some damage to the body may already start occurring during prediabetes — a condition in which your blood sugar is higher than normal but not high enough to be considered diabetes. Research has shown that if you have prediabetes, you can reduce your risk of developing type 2 diabetes by almost 60 percent through lifestyle changes. These changes include increasing your physical activity and modest weight loss — losing as little as 5 to 7 percent of your current weight. That's a huge risk reduction from small changes!

Ultimately, diabetes is a chronic health condition that can affect many aspects of your health. It's important that you take high blood sugar seriously. Regular follow-up care may help you better manage the disease and live an active, healthy life.

Peggy

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Dear friends of the depression blog,

Thank you for continuing the conversation even though there's been a gap in postings from us. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)Dr. Melin's been drawn into some other responsibilities of late and that's why we've had a break in our expert postings.

We don't intend to leave this blog without an expert for long. Please stay with us during this delay. We hope MayoClinic.com will continue to be a place where you can share your thoughts about the trials of living with depression.

- Medical editor-in-chief Roger W. Harms, M.D.

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A diabetes lifestyle is a demanding one, in which the majority of management is self-care. The key to managing your diabetes involves testing your blood sugar; taking diabetes medications, insulin or both; eating a healthy, balanced diet; exercising; caring for your feet; stopping smoking; and keeping your diabetes appointments with your provider. If you don't do these things, you're at great risk of developing diabetes complications.

Research has proven that complications are less likely to occur if you keep your blood glucose as near to normal as possible, yet, as diabetes educators, we hear many reasons why our clients don't make simple changes to better their own health. Here are a few.

"I'm too young to have diabetes." This is a form of denial. According to the Centers for Disease Control and Prevention (CDC), more than 13,000 young people are diagnosed with type 1 diabetes in the United States each year. The number of children and adolescents diagnosed with type 2 diabetes is growing at an alarming rate. New diagnoses for type 2 diabetes in children accounts for up to half of all diabetes diagnoses in children and adolescents."I don't have enough time." Whether you work full-time or stay at home, it's important to take time to improve your way of life. Managing your blood sugar doesn't require you to make drastic changes. Break tasks down into smaller, doable actions. For example, take a 10-minute walk twice a day instead of walking for 20 minutes at one time. There are, however, things you must make time for. To stay healthy, you must test your blood sugar and take your diabetes medications."I feel fine. Maybe high blood sugar is normal for me." High blood sugar is never normal. Normal blood sugar for people who don't have diabetes is 70 to 100 mg/dL (3.9 to 5.6 mmol/L). Diabetes is an insidious disease, often called a silent killer. You may feel fine, but damage is being done to your entire body, from your hearing and vision, to sexual function, to mental health and sleep.

Other comments we hear include everything from "I don't like vegetables" to "Lifestyle changes won't work, so just give me diabetes pills."

But no change is too small to ward off type 2 diabetes or to delay further progression of diabetes! A large, national study conducted at 27 sites around the U.S. found that small lifestyle changes are far more successful at warding off diabetes or delaying further progression of the disease than are medications. The Diabetes Prevention Program (DPP) found that participants who lost a modest amount of weight through dietary changes and increased physical activity greatly reduced their chances of developing diabetes or developing further complications of diabetes.

Get started today and set a specific goal. Choose a lifestyle change that you're willing to work on. Don't change behaviors that will make your health care team happy — change for you. Ask yourself what you'd like to change and how you're going to do it, for how long, and how many days of the week. Start with one specific, attainable goal, for example, "I will walk 10 to 15 minutes three days a week for one month."

Lifestyle changes take patience, but, with persistence, you can make them happen.

Peggy

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It seems to be common sense that hard times are associated with developing depressive symptoms. When a personal crisis occurs, many people who had been coping pretty well become clinically depressed.

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The two classic examples are losing a relationship or losing a job. However, if a company terminates 100 employees, most of them don't develop a depressive illness. An important question is why one employee manages to cope while another develops a mood disorder.

Seven years ago, an important paper published in one of our most respected scientific journals reported that people with a genetic variant of the serotonin transporter gene were more likely to become depressed when they had experienced stressful situations.

If a person had this genetic variant and wasn't exposed to very stressful situations, they weren't any more vulnerable to depression than if they had the more protective form of the gene. It was only when they had experienced severe personal distress that their depressive symptoms occurred. People without this genetic variant were often able to tolerate quite severe stress and not develop symptoms.

There has been much discussion of this finding. Many studies were done that measured stressful experiences in a variety of different ways. About a year ago, a paper reviewed only 14 of these studies and concluded that people with this genetic variant weren't very much more vulnerable to stress. There were problems with this analysis, but it was published in a good journal and it made some doctors a bit skeptical about the finding.

This week, a new analysis of 56 studies concluded that there was a strong relationship. They demonstrated that people with the less active form of the serotonin transporter gene were more vulnerable to developing depression when they experienced severe stress.

The analysis found:

The strongest relationship was between severe stresses during childhood that then seemed to haunt the person for the rest of their life. This finding supports the view that young children are particularly vulnerable and that early abusive experiences can have a long lasting impact. The next most difficult type of stress was serious medical problems. This also makes sense as we have known for many years that some people become very depressed when faced with the prospect of having to deal with a serious medical illness.The least dangerous kind of stress was the hassles of everyday living that we're all familiar with and that sometimes get out of hand. However, even this kind of stress was associated with an increased risk of depression if a person had this genetic variant.

The bottom line is that this new analysis provides strong evidence that stress can trigger depression and that the onset of depression is far more likely in people who are genetically vulnerable to developing a mood disorder.

Does this mean that if you have the variant, you are doomed to become depressed? Absolutely not. It just means that you're more vulnerable to developing symptoms.

Does the study prove that if you don't have the variant, you won't develop a depression if you're exposed to intense stress? Again, absolutely not. It just means that the risk is lower.

Perhaps the most important point that this analysis makes is that there is a biological vulnerability to depression just like there is a biological vulnerability to diabetes, asthma, or cancer.

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Hello, bloggers. I've been looking at articles from a number of popular diabetes magazines and other resources about diabetes myths. Each one seems to have its own list of the top five or 10 diabetes myths.

I decided to develop my own list of the top 10 diabetes myths that I've heard as a diabetes educator at the Mayo Clinic in Rochester, Minn. I'll reveal five this week, five next week.

Here goes (drum roll).

I have borderline diabetes or just a touch of diabetes.

Either you have it or you don't. Two fasting blood sugar readings over 126 milligrams per deciliter (mg/dL) or 7 millimoles per liter (mmol/L); a random blood glucose over 200 mg/dL (11.1 mmol/L); or an A1C of 6.5 percent or higher are all considered diabetes.

I don't know why I got diabetes, I never eat sweets.

Just about everything you eat is converted into glucose — sugar — so for most people with type 2 diabetes, what you eat is not as important as how much you eat. When you overeat, you're adding extra calories your body doesn't need for energy, so your body will convert these extra calories into fat. Being overweight is a predisposing factor for developing diabetes. 

I can't eat carbohydrates; it makes my blood sugars go high.

Of course they do — even people who don't have diabetes will see an elevation in their blood glucose after eating. Carbohydrates should be approximately 50 percent of your daily food intake each day. Carbohydrates are your fuel, without them you will have little energy.

If I have to go on insulin; that must mean my diabetes is really bad.

You know, insulin has gotten a bad rap through the years. It's the blood glucose control that determines whether you go on insulin; if diet alone or diet along with oral or noninsulin-injectable diabetes medication(s) is not controlling the blood glucose, insulin is necessary.

Insulin causes complications of diabetes.

Again, insulin has gotten a bad rap. Insulin is a natural hormone and is probably one of the safest medications around. Insulin helps control the blood glucose, which in turn slows down or prevents diabetes complications.

Your thoughts? What are some of the diabetes myths you have come across?

Have a great week,

Nancy

I love technology and all the gadgets that go along with it, including diabetes apps (applications) that help with managing diabetes. I recently read in Health Data Management news that the use of mobile and internet tools helped a group of people with diabetes lower their blood glucose levels. The group that used these tools saw an average A1C level decrease of almost 2 percent, which was more than twice the decrease seen in the control group. Other research has shown that even a 1 percent decrease in A1C helps to prevent complications of diabetes.

I typed in "diabetes" on my mobile device and downloaded several different diabetes apps that aim to help with managing diabetes. Costs varied from free to around $12. You have many diabetes apps to choose from to quickly record your blood sugar, blood pressure, pulse, weight, medications, food (usually carbohydrates) and exercise. You even have the ability to print or email your blood glucose record to your health care provider.

In our practice, I find that most people don't mind testing their blood sugar, but they don't care for writing down their readings. We understand busy schedules and know that it can be difficult to find the time to test your blood sugar, let alone write it down. However, keeping a record of your blood sugar levels can help you identify patterns of blood sugar levels that are too high or too low. A blood sugar record also helps your health care team evaluate the effectiveness of your diabetes medications, including insulin.

If you're comfortable with the technology, consider a mobile diabetes app to help you record your blood sugar levels. Mobile technology isn't for everyone, and that's all right! But it can be a good option for many.

We'd love to hear your experiences with mobile technology and diabetes management.

Peggy

It's all too clear that while many of you experience a dramatic positive response to antidepressant medications, others are frustrated and angry with the ineffectiveness of the treatment you've received.

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1-800-950-NAMI (6264)

It's long been recognized that electroconvulsive therapy is an effective treatment, but the cost is high and problems with memory following treatment are not uncommon. For many years, treatment resistant patients have been waiting for an alternative treatment. In 2009, the FDA approved transcranial magnetic stimulation (TMS) as an alternative form of treatment for these individuals.

While transcranial magnetic stimulation has its own limitations, it can be quite effective for those of you who don't tolerate treatment with medications and aren't willing to consider electroconvulsive therapy. Since the FDA approval, the treatment has become much more widely available. While new strategies for providing TMS are being developed, the basic strategy is to provide daily treatments that last for approximately 40 minutes and don't require anesthesia.

A real advantage of transcranial magnetic stimulation is that it has a very low incidence of side effects. While some patients can begin to feel better during the first week, others require as many as six weeks before their depression resolves. While we are only beginning to understand the factors that increase the risk for relapse following a full course of treatment, some evidence suggests that a relatively modest number of ongoing treatments will maintain a positive effect.

The biggest barrier to obtaining transcranial magnetic stimulation at this point in time is concern about insurance coverage. However, as the efficacy of TMS becomes more firmly established, it's likely that insurance coverage will become more universal. The bottom line if you've struggled with antidepressant medications is that there's now an effective and safe alternative treatment.

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It's well known that depression symptoms can be caused or worsened by many medical illnesses. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)One of these is thyroid disease.

Your thyroid gland is important in controlling metabolism. If it's not functioning properly, it can affect your mood. Your thyroid can be underactive or overactive, as well as normal.

Interestingly, there is a thyroid hormone produced by your brain that travels through your bloodstream to the thyroid gland in your neck. The thyroid gland, in turn, produces other hormones that regulate metabolism.

Your health care provider may check your thyroid with a blood test. Additionally, thyroid hormone is sometimes added to the antidepressant you are currently on to give it a boost.

Some medical conditions preclude the use of oral thyroid hormone. Talk with your health care provider about options as not everyone is a candidate for this.

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A patient shared the following story:

She was in a grocery store and felt that something was wrong, so she walked over to the checkout lane and grabbed a couple candy bars off the shelf. She stood there in a daze, clutching the candy bars in her hands but not eating them. She must have looked like she needed help, because a woman walked over to her and asked if she had diabetes. The woman told her to open the candy bar wrapper and eat the candy right away. My patient was in such a confused state that she hadn't thought to do that herself. The woman stayed with her until she felt better and told her that she had a family member with diabetes, who she'd assisted before when he or she was in a similar confused state of low blood glucose (hypoglycemia). My patient was lucky to have received this assistance and avoided the need for an emergency medical response team (911) call for the seizures or unconsciousness that could have occurred with severe hypoglycemia.

Is this scenario familiar to you or a family member or friend with long-standing diabetes? This story is an example of "hypoglycemia unawareness" — a condition in which a person with diabetes doesn't experience the usual warning symptoms of hypoglycemia.

Usually, when a person's blood glucose drops, the body tries to raise it by releasing the hormones glucagon and epinephrine. Glucagon spurs the liver to release stored glucose from the liver into the bloodstream. Epinephrine signals the liver to produce more glucose and also causes the typical early warning signs of hypoglycemia — sweatiness, shakiness and weakness.

If you experience hypoglycemia unawareness, you skip these warning symptoms. Instead, without warning, you can lapse into severe hypoglycemia, becoming confused, disoriented or unconscious. This is because when you've had diabetes a long time, or experienced frequent, extreme swings of high to low blood glucose levels, you can lose the epinephrine response to low blood glucose.

In the next blog, I'll discuss more features of hypoglycemia unawareness, including the predisposing factors and possible treatment strategies for this condition.

Until next time, have a good week.

Nancy

Some of you have been interested in the recent discussion of pharmacogenetic testing and have asked if it's available. Yes, it's available, but many psychiatrists aren't yet comfortable with interpreting the results.

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The Mayo Medical Laboratory began testing in 2003 to determine whether people could tolerate certain antidepressants. In a relatively short time, other large medical laboratories also began offering these tests.

Two things have happened to improve access to testing:

First, a company called AssureRx Health was created to provide the results of these tests to psychiatrists using a more "physician friendly" report. A psychiatrist can now collect just a simple cheek swab sample of DNA, send it overnight to AssureRx and receive the results electronically within 36 to 48 hours.Second, more than 2,000 psychiatrists have taken a Mayo Clinic course designed to help them use this testing more efficiently.

By incorporating new research results from ongoing scientific studies, the testing is getting increasingly more accurate. While the results still can't provide a certain prediction of which antidepressant will be most effective, the tests do increase the chances of identifying an effective medication and can definitely identify medications that you're unlikely to be able to tolerate.

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Before people develop type 2 diabetes, they usually have prediabetes or impaired fasting blood glucose. If your blood sugar level is over 100 mg/dL (5.5 mmol) but less than 126 mg/dL (7 mmol), you're considered to have prediabetes.

Prediabetes/diabetes has become a worldwide epidemic. There are 57 million people in the United States alone who have prediabetes and most don't know it, according to the American Diabetes Association.

Unfortunately, many people who believe they're "borderline diabetic" or have "a touch of diabetes" think that they're safe. However, research has shown that some long-term damage is being done to the body, especially to the heart and circulatory system.

You're overweight or obese. This can keep your body from making and using insulin properly. Being overweight can also cause high blood pressure.You have a parent, brother or sister with diabetes. If you have a relative with type 2 diabetes, this more than doubles your risk of getting the disease.You're African-American, American Indian, Asian-American, Pacific Islander or of Hispanic/Latino heritage.You had gestational diabetes or gave birth to at least one baby who weighed more than 9 pounds (4.1 kilograms).You have high blood pressure.Your HDL or "good" cholesterol is below 35 mg/dL (0.9 mmol/L) or your triglyceride level is above 250 mg/dL (2.83 mmol/L).You exercise fewer than three times a week.

You can have prediabetes and not know it. Two tests are commonly used to diagnose prediabetes:

Fasting blood glucose. Measures blood glucose first thing in the morning before you eat. A normal fasting blood glucose is between 70 to100 mg/dL (3.8 to 5.5 mmol). You have prediabetes if your fasting blood sugar is 101 to 125 mg/dL (5.6 to 6.9 mmol).Oral glucose tolerance test. Measures blood glucose after fasting and again 2 hours after drinking a glucose-rich drink. Normal blood glucose is below 140 mg/dL (7.7 mmol) 2 hours after the drink. In prediabetes, the 2-hour blood glucose is 140 to 199 mg/dL (7.8 to 11.0 mmol/L). If the 2-hour blood glucose rises to 200 mg/dL (11.1 mmol) or above, you have diabetes.

If you have prediabetes, you should do something about it. Studies have shown that people with prediabetes can prevent or delay the development of type 2 diabetes by up to 58 percent through changes to their lifestyle, including modest weight loss (as little as 5 to 7 percent of your current weight) and increasing physical exercise. That is huge!

- Peggy

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Pharmacogenomics is a new field of study in medicine. It involves the identification of genetic variations that predict the response of a patient to a medication. Pharmacogenomics is relevant for all types of drugs such as medications for asthma or hypertension. It's now possible to use pharmacogenomic testing to help select an antidepressant.

In a previous blog, I discussed the relationship between a variant of the serotonin transporter gene and vulnerability to developing depression when faced with severe stress. If you have the more active form of this gene, you're less likely to develop depression even if you find yourself in a stressful situation. However, if you have the more active form of this gene and do become depressed, you're more likely to get better if you take a selective serotonin reuptake inhibitor (SSRI) antidepressant like Prozac (fluoxetine), Paxil (paroxetine), or Celexa (citalopram).

The probability of a good response to an SSRI is particularly high if you identify yourself as being "white." This suggests that other gene variations that are more common in patients of European ancestry may also influence the response of these patients to SSRI's.

For several years, it's been known that patients with the more active form of the serotonin transporter gene are more likely to respond to SSRI treatment. However, it's only been possible to test patients to see whether they have a more or less active form of this gene for the past three years. Based on the results of this pharmacogenomic testing, a psychiatrist is now able to develop a better understanding of what the probability will be for a specific patient achieving a good clinical outcome. The primary goal of testing is simply to be able to avoid side effects and identify an effective antidepressant medication more quickly.

To be able to get an even more accurate prediction of response, it will ultimately be necessary to test more than any one single gene as many genes influence the probability of responding to treatment. As testing becomes more sophisticated, there's every reason to believe that treatment outcomes will continue to improve. For many of you struggling with depression, the fact that there are now many researchers working to better understand antidepressant medication response should provide some hope.

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Who should receive transcranial magnetic stimulation (TMS)?

Experience with TMS makes it clear that not all patients respond to this treatment, but it also demonstrates that some do.  The success rate varies as a consequence of a number of factors, but the type and severity of the depression makes a difference.

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1-800-950-NAMI (6264)

TMS works best for patients with moderate depression who don't tolerate antidepressant medications.  TMS is unlikely to work if you've received electro-convulsant therapy (ECT) and weren't helped by it.

TMS is still a quite new treatment. Psychiatrists vary in their experience using it and their confidence in its effectiveness. The most attractive features of TMS are that it's quite safe and effective for some patients. The biggest drawbacks are that it doesn't help some patients, it can take several weeks to begin to work, and is quite expensive.

If you're struggling with depression, you must ultimately decide whether TMS is the right treatment. A decision should be made on the basis of a frank discussion between a knowledgeable psychiatrist and an informed patient.  Once you understand the potential benefits and risks as well as the cost, the decision should be made as to whether the potential gain is worth the cost. Beginning a new treatment is not usually an easy decision, but it should be a joint decision based on the available evidence.

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